Organization
DR MICHAEL DIVAK PSYCHOLOGIST
Active
Other names
DR MICHAEL DIVAK PSYCHOLOGIST
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL NORMAN DIVAK PHD (SOLE PROPRIETOR)
(518) 673-6001
Entity
Organization
Contact information
Practice address
66 MONTGOMERY ST STE 2, CANAJOHARIE, NY 13317-1212
(518) 673-6001
Mailing address
66 MONTGOMERY ST, CANAJOHARIE, NY 13317-1212
(518) 673-6001
(518) 673-6033
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
021046-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
021046
NEW YORK STATE OFFICE OF THE PROFESSIONS. LICENSE
NY
05
—
04054899
—
NY
01
—
846977
BEACON HEALTH OPTIONS, INC
VA
01
—
PRC200309433
CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN
NY
Enumeration date
08/23/2018
Last updated
08/23/2018
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