Provider Demographics
NPI:1376513069
Name:PETERSON, MICHAELA A (DC, FACO)
Entity Type:Individual
Prefix:DR
First Name:MICHAELA
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC, FACO
Other - Prefix:DR
Other - First Name:MICHAELA
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, FACO
Mailing Address - Street 1:36 WOODVALE RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3927
Mailing Address - Country:US
Mailing Address - Phone:203-481-0510
Mailing Address - Fax:
Practice Address - Street 1:650 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3613
Practice Address - Country:US
Practice Address - Phone:203-481-6150
Practice Address - Fax:203-481-0411
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT0469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTOV4757OtherHEALTHNET
CT050000469CT01OtherBCBS
CTNHS019OtherOXFORD/TRIAD
CT350052269OtherRAILROAD MEDICARE
CT046900OtherCTCARE
CTCT00469OtherLANDMARK
CTOV4757OtherHEALTHNET
CTCT00469OtherLANDMARK