Provider Demographics
NPI:1639255524
Name:POVINELLI, PAUL THADDEUS (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THADDEUS
Last Name:POVINELLI
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 1:45 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9103
Mailing Address - Country:US
Mailing Address - Phone:607-387-5741
Mailing Address - Fax:607-387-5575
Practice Address - Street 1:45 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-9103
Practice Address - Country:US
Practice Address - Phone:607-387-5741
Practice Address - Fax:607-387-5575
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY8450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9534847Medicaid
NY111354OtherVALUE OPTIONS
NYSO8450-9OtherWORKERS COMPENSATION
NY50998BMedicare ID - Type Unspecified