Provider Demographics
NPI:1770680324
Name:D'ELENA, PETER (PSYD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:D'ELENA
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 1:34 MORNING DR
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2317
Mailing Address - Country:US
Mailing Address - Phone:631-786-8930
Mailing Address - Fax:
Practice Address - Street 1:1650 SYCAMORE AVE
Practice Address - Street 2:SUITE 18
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1738
Practice Address - Country:US
Practice Address - Phone:631-786-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015937103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400024419Medicare UPIN