Provider Demographics
NPI:1134644347
Name:PETERSON, DESIRAE
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COURT ST STE 3
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-1273
Mailing Address - Country:US
Mailing Address - Phone:860-613-9930
Mailing Address - Fax:
Practice Address - Street 1:110 COURT ST STE 3
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-1273
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst