Healthcare Provider Details

I. General information

NPI: 1699733261
Provider Name (Legal Business Name): KEITH DANIEL PETROSKY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 EXTON CMNS
EXTON PA
19341-2450
US

IV. Provider business mailing address

308 EXTON CMNS
EXTON PA
19341-2450
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-6155
  • Fax: 610-363-6116
Mailing address:
  • Phone: 610-363-6155
  • Fax: 610-363-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS004244L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0390500000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAMERIHEALTH
# 2
Identifier001662734
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerIBC PERSONAL CHOICE
# 3
Identifier2123008
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerUNITED HEALTHCARE
# 4
Identifier354872000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMAGELLAN
# 5
Identifier2119379
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCIGNA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: