Provider Demographics
NPI:1326024332
Name:PEETOOM, GREG ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:ALAN
Last Name:PEETOOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20470 N LAKE PLEASANT RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9708
Mailing Address - Country:US
Mailing Address - Phone:714-474-6836
Mailing Address - Fax:623-933-8625
Practice Address - Street 1:20470 N LAKE PLEASANT RD STE 106
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382
Practice Address - Country:US
Practice Address - Phone:714-474-6836
Practice Address - Fax:623-933-8625
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26262103T00000X
AZPSY3097103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0612460OtherBLUE CROSS OF ARIZONA
AZR17239Medicare ID - Type UnspecifiedMEDICARE