Provider Demographics
NPI:1578255006
Name:PETERSEN, MICHAEL I
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETERSEN
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 8TH AVE FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-2486
Mailing Address - Country:US
Mailing Address - Phone:800-679-3609
Mailing Address - Fax:
Practice Address - Street 1:5 LEMNAH DR
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-2382
Practice Address - Country:US
Practice Address - Phone:800-679-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst