Provider Demographics
NPI:1477619252
Name:HOMENICK, MICHAEL P (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:HOMENICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 BAY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1441
Mailing Address - Country:US
Mailing Address - Phone:518-798-4056
Mailing Address - Fax:518-798-4255
Practice Address - Street 1:551 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1441
Practice Address - Country:US
Practice Address - Phone:518-798-4056
Practice Address - Fax:518-798-4255
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008202103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01035914Medicaid
NY000463033002OtherBLUE SHIELD
NY41136OtherMOHAWK VALLEY PHYSICIANS
NY000463033002OtherBLUE SHIELD