Provider Demographics
NPI:1891891131
Name:PETEROY, EDWARD THOMAS
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:THOMAS
Last Name:PETEROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1562
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80901-1562
Mailing Address - Country:US
Mailing Address - Phone:719-599-7882
Mailing Address - Fax:719-598-1437
Practice Address - Street 1:1935 DOMINION WAY
Practice Address - Street 2:SUITE A102
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1464
Practice Address - Country:US
Practice Address - Phone:719-599-7882
Practice Address - Fax:719-598-1437
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO970103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical