MEDICARE: PETER D'ELENA 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	103TC0700X	Clinical Psychologist	015937	NY

General Provider Information

NPI Number	:	1770680324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER D'ELENA PSY.D.

Provider Business Mailing Address
First Line	:	34 MORNING DR
Second Line	:
City	:	CENTEREACH
State	:	NY
Zip	:	11720-2317
Country	:	US
Telephone Number	:	631-786-8930
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 SYCAMORE AVE
Second Line	:	SUITE 18
City	:	BOHEMIA
State	:	NY
Zip	:	11716-1738
Country	:	US
Telephone Number	:	631-786-8930
Fax Number	:

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	02/19/2013

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