Healthcare Provider Details

I. General information

NPI: 1164825527
Provider Name (Legal Business Name): MICHAEL WALES MASTER SCHOOL PSYCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1347 SNYDER RD
ALFRED STATION NY
14803-9738
US

IV. Provider business mailing address

1347 SNYDER RD
ALFRED STATION NY
14803-9738
US

V. Phone/Fax

Practice location:
  • Phone: 607-382-5866
  • Fax:
Mailing address:
  • Phone: 607-382-5866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: