Healthcare Provider Details

I. General information

NPI: 1497344881
Provider Name (Legal Business Name): MATTHEW MICHAEL PETTERSEN DPT, CFMT, FAAOMPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VALLEY RD
COS COB CT
06807-2533
US

IV. Provider business mailing address

71 VINCENT AVE
STAMFORD CT
06905-4023
US

V. Phone/Fax

Practice location:
  • Phone: 203-957-5503
  • Fax:
Mailing address:
  • Phone: 917-992-2876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number013223
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: