Provider Demographics
NPI:1104839836
Name:DEMARTINO, RICHARD ALBERT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALBERT
Last Name:DEMARTINO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MERIDIAN LN
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1327
Mailing Address - Country:US
Mailing Address - Phone:518-877-7358
Mailing Address - Fax:518-877-7213
Practice Address - Street 1:331 USHERS ROAD
Practice Address - Street 2:NORTHWAY 10 PROFESSIONAL PARK
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019-1327
Practice Address - Country:US
Practice Address - Phone:518-877-7358
Practice Address - Fax:518-877-7213
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10002103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist