Provider Demographics
NPI:1861476574
Name:PETERSON, MIKELLE MARIE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MIKELLE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29670 COUNTY ROAD 372A
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-9704
Mailing Address - Country:US
Mailing Address - Phone:303-862-1840
Mailing Address - Fax:
Practice Address - Street 1:29670 COUNTY ROAD 372A
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211-9704
Practice Address - Country:US
Practice Address - Phone:303-862-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO673379OtherBC/BS OF COLORADO
CO14387018Medicaid
CO72435313Medicaid
CO673379OtherBC/BS OF COLORADO
CO801966Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER