Healthcare Provider Details

I. General information

NPI: 1265415921
Provider Name (Legal Business Name): ALAN PETROSKI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2005
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1264 WYOMING AVE
FORTY FORT PA
18704-4138
US

IV. Provider business mailing address

36 COSLETT LN
HUNLOCK CREEK PA
18621-4014
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-8795
  • Fax: 570-718-1786
Mailing address:
  • Phone: 570-477-5608
  • Fax: 570-477-5542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS008935L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: