MEDICARE: DR. RICHARD ALBERT DEMARTINO PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	10002	NY

General Provider Information

NPI Number	:	1104839836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD ALBERT DEMARTINO PSY.D.

Provider Business Mailing Address
First Line	:	23 MERIDIAN LN
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-1327
Country	:	US
Telephone Number	:	518-877-7358
Fax Number	:	518-877-7213

Provider Business Practice Location Address
First Line	:	331 USHERS ROAD
Second Line	:	NORTHWAY 10 PROFESSIONAL PARK
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-1327
Country	:	US
Telephone Number	:	518-877-7358
Fax Number	:	518-877-7213

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/08/2007

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