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General NPI Number Information
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NPI Number | 1104238294
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Entity Type | Organization
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Legal Business Name | ANDREA G DERTANY PSYD
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Dates
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Enumeration Date | 05/23/2014
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Last Update Date | 05/23/2014
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Provider Practice Location Address
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Address Line | 105 S RIVERSIDE DR STE 130
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City | INDIALANTIC
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State | FL
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Zip | 32903-4321
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Country | US
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Telephone | 321-727-9031
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Fax | 321-724-8011
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Provider Business Mailing Address
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Address Line | 105 S RIVERSIDE DR STE 130
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City | INDIALANTIC
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State | FL
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Zip | 32903-4321
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Country | US
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Telephone | 321-727-9031
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Fax | 321-724-8011
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Authorized Official
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Title or Position | ADMIN ASSISTANT
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Name | BECKIE REEL
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Credential |
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Telephone | 321-727-9031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY4374
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License Number State | FL
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