Provider Demographics
NPI:1265415921
Name:PETROSKI, ALAN (PHD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:PETROSKI
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 1:36 COSLETT LN
Mailing Address - Street 2:
Mailing Address - City:HUNLOCK CREEK
Mailing Address - State:PA
Mailing Address - Zip Code:18621-4014
Mailing Address - Country:US
Mailing Address - Phone:570-477-5608
Mailing Address - Fax:570-477-5542
Practice Address - Street 1:1264 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4138
Practice Address - Country:US
Practice Address - Phone:570-288-8795
Practice Address - Fax:570-718-1786
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-26
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008935L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0853152Medicaid
OH0853152Medicaid