Provider Demographics
NPI:1508284704
Name:DIVAK, MICHAEL NORMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:NORMAN
Last Name:DIVAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:N
Other - Last Name:DIVAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYCHOLOGIST
Mailing Address - Street 1:66 MONTGOMERY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CANAJOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:13317-1212
Mailing Address - Country:US
Mailing Address - Phone:518-673-6001
Mailing Address - Fax:518-673-6033
Practice Address - Street 1:66 MONTGOMERY ST STE 2
Practice Address - Street 2:
Practice Address - City:CANAJOHARIE
Practice Address - State:NY
Practice Address - Zip Code:13317-1212
Practice Address - Country:US
Practice Address - Phone:518-673-6001
Practice Address - Fax:518-673-6033
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021046-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021046OtherLICENSE PSYCHOLGIST
NY021046OtherNEW YORK STATE OFFICE OF PROFESSION