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General NPI Number Information
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NPI Number | 1831246792
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGICAL ASSOCIATES OF NORTHEASTERN NEW YORK PC
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 551 BAY RD
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City | QUEENSBURY
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State | NY
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Zip | 12804-1280
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Country | US
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Telephone | 518-798-4056
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Fax | 518-798-4255
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Provider Business Mailing Address
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Address Line | 551 BAY RD.
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City | QUEENSBURY
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State | NY
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Zip | 12804-1280
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Country | US
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Telephone | 518-798-4056
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Fax | 518-798-4255
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL P HOMENICK
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Credential | PHD
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Telephone | 518-798-4056
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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 |
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License Number State |
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