=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376513069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAELA A PETERSON DC, FACO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2006
-----------------------------------------------------
Last Update Date | 01/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 MAIN ST
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-481-6150
-----------------------------------------------------
Fax | 203-481-0411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 WOODVALE RD
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-481-0510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CT0469
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------