Provider Demographics
NPI:1699733261
Name:PETROSKY, KEITH DANIEL (PHD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DANIEL
Last Name:PETROSKY
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 1:308 EXTON CMNS
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2450
Mailing Address - Country:US
Mailing Address - Phone:610-363-6155
Mailing Address - Fax:610-363-6116
Practice Address - Street 1:308 EXTON CMNS
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2450
Practice Address - Country:US
Practice Address - Phone:610-363-6155
Practice Address - Fax:610-363-6116
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004244L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0390500000OtherAMERIHEALTH
PA001662734OtherIBC PERSONAL CHOICE
PA2123008OtherUNITED HEALTHCARE
PA354872000OtherMAGELLAN
PA2119379OtherCIGNA