MEDICARE: ANDREA G DERTANY PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY4374	FL

General Provider Information

NPI Number	:	1104238294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREA G DERTANY PSYD

Provider Business Mailing Address
First Line	:	105 S RIVERSIDE DR STE 130
Second Line	:
City	:	INDIALANTIC
State	:	FL
Zip	:	32903-4321
Country	:	US
Telephone Number	:	321-727-9031
Fax Number	:	321-724-8011

Provider Business Practice Location Address
First Line	:	105 S RIVERSIDE DR STE 130
Second Line	:
City	:	INDIALANTIC
State	:	FL
Zip	:	32903-4321
Country	:	US
Telephone Number	:	321-727-9031
Fax Number	:	321-724-8011

Authorized Official
Title or Position	:	ADMIN ASSISTANT
Name	:	BECKIE REEL
Credential	:
Telephone Number	:	321-727-9031

Provider Enumeration Date	:	05/23/2014
Last Update Date	:	05/23/2014

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