Provider Demographics
NPI:1679054167
Name:DR MICHAEL DIVAK PSYCHOLOGIST
Entity Type:Organization
Organization Name:DR MICHAEL DIVAK PSYCHOLOGIST
Other - Org Name:DR MICHAEL DIVAK PSYCHOLOGIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:DIVAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-673-6001
Mailing Address - Street 1:66 MONTGOMERY ST
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021046-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA846977OtherBEACON HEALTH OPTIONS, INC
NYPRC200309433OtherCAPITAL DISTRICT PHYSICIANS' HEALTH PLAN
NY021046OtherNEW YORK STATE OFFICE OF THE PROFESSIONS. LICENSE
NY04054899Medicaid