Provider Demographics
NPI:1689974487
Name:PETERS, MELISSA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 OLD COUNTRY RD STE B3
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2060
Mailing Address - Country:US
Mailing Address - Phone:631-591-2210
Mailing Address - Fax:631-591-2211
Practice Address - Street 1:1149 OLD COUNTRY RD STE B3
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2060
Practice Address - Country:US
Practice Address - Phone:631-591-2210
Practice Address - Fax:631-591-2211
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004487171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist