Provider Demographics
NPI:1538228838
Name:PETROSKY, GREGORY (EDD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:PETROSKY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 COLLEGE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-1156
Mailing Address - Country:US
Mailing Address - Phone:413-532-3125
Mailing Address - Fax:
Practice Address - Street 1:29 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-1156
Practice Address - Country:US
Practice Address - Phone:413-532-3125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6943103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1891022Medicaid
MAW50255Medicare ID - Type Unspecified