Provider Demographics
NPI:1124322185
Name:WILLIAM D PETOK, PHD, PA
Entity type:Organization
Organization Name:WILLIAM D PETOK, PHD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PETOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-647-9166
Mailing Address - Street 1:479 JUMPERS HOLE RD
Mailing Address - Street 2:SUITE 304B
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1600
Mailing Address - Country:US
Mailing Address - Phone:410-647-9166
Mailing Address - Fax:410-647-9174
Practice Address - Street 1:479 JUMPERS HOLE RD
Practice Address - Street 2:SUITE 304B
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-1600
Practice Address - Country:US
Practice Address - Phone:410-647-9166
Practice Address - Fax:410-647-9174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty