Healthcare Provider Details

I. General information

NPI: 1780053231
Provider Name (Legal Business Name): TODD DENEEN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 OFFICE PKWY STE 125
PITTSFORD NY
14534-1781
US

IV. Provider business mailing address

28 LARKSPUR LN
FAIRPORT NY
14450-9207
US

V. Phone/Fax

Practice location:
  • Phone: 585-749-8372
  • Fax:
Mailing address:
  • Phone: 585-749-8372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number022010-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2015032101
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number022010-01
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number022010-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: