Healthcare Provider Details

I. General information

NPI: 1053566000
Provider Name (Legal Business Name): MICHAEL P. ANDRONICO, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CEDAR GROVE LN SUITE 103 G
SOMERSET NJ
08873-4719
US

IV. Provider business mailing address

107 CEDAR GROVE LN SUITE 103 G
SOMERSET NJ
08873-4719
US

V. Phone/Fax

Practice location:
  • Phone: 732-564-9500
  • Fax: 732-564-9501
Mailing address:
  • Phone: 732-564-9500
  • Fax: 732-564-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35S100065500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number35S100065500
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHAEL P. ANDRONICO
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 732-564-9500