Provider Demographics
NPI:1689818148
Name:PETIFORD, LAURA (PMHNP, LMFT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:PETIFORD
Suffix:
Gender:F
Credentials:PMHNP, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BEAUMONT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 KINGS HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5321
Practice Address - Country:US
Practice Address - Phone:203-445-6238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001309106H00000X
CT006417363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist