Healthcare Provider Details

I. General information

NPI: 1790016277
Provider Name (Legal Business Name): MICHAEL ANTHONY POLITO JR. PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE
BETHESDA MD
20889-7106
US

IV. Provider business mailing address

915 E ST NW APT 601
WASHINGTON DC
20004-2016
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-1234
  • Fax:
Mailing address:
  • Phone: 773-771-7969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0003791
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: