Provider Demographics
NPI:1902320724
Name:PETIT, MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETIT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 SAYBROOK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4780
Mailing Address - Country:US
Mailing Address - Phone:860-685-8940
Mailing Address - Fax:
Practice Address - Street 1:410 SAYBROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4780
Practice Address - Country:US
Practice Address - Phone:860-685-8940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist