Provider Demographics
NPI:1962504845
Name:PETROSKY, EDWARD MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MICHAEL
Last Name:PETROSKY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14950 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3131
Mailing Address - Country:US
Mailing Address - Phone:917-520-4444
Mailing Address - Fax:
Practice Address - Street 1:6812 YELLOWSTONE BLVD
Practice Address - Street 2:AA1
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3268
Practice Address - Country:US
Practice Address - Phone:917-520-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015033-2103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ09986Medicare UPIN
NY06191Medicare PIN