MEDICARE: DR. MICHAEL NORMAN DIVAK PH.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	103TC0700X	Clinical Psychologist	021046-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	021046	OTHER	NY	LICENSE PSYCHOLGIST
2	021046	OTHER	NY	NEW YORK STATE OFFICE OF PROFESSION

General Provider Information

NPI Number	:	1508284704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL NORMAN DIVAK PH.D.

Provider Business Mailing Address
First Line	:	66 MONTGOMERY ST STE 2
Second Line	:
City	:	CANAJOHARIE
State	:	NY
Zip	:	13317-1212
Country	:	US
Telephone Number	:	518-673-6001
Fax Number	:	518-673-6033

Provider Business Practice Location Address
First Line	:	66 MONTGOMERY ST STE 2
Second Line	:
City	:	CANAJOHARIE
State	:	NY
Zip	:	13317-1212
Country	:	US
Telephone Number	:	518-673-6001
Fax Number	:	518-673-6033

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

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	08/22/2018

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