Provider Demographics
NPI:1265489025
Name:PETOSKEY, MARTHA DESCHAMPS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:DESCHAMPS
Last Name:PETOSKEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 WILLING LAKES CT
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-1861
Mailing Address - Country:US
Mailing Address - Phone:864-384-9002
Mailing Address - Fax:
Practice Address - Street 1:261 GREENGATE LN
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-2211
Practice Address - Country:US
Practice Address - Phone:864-494-0928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC881103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP8965Medicaid