Provider Demographics
NPI:1104238294
Name:ANDREA G DERTANY PSYD
Entity type:Organization
Organization Name:ANDREA G DERTANY PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:BECKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-727-9031
Mailing Address - Street 1:105 S RIVERSIDE DR STE 130
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4321
Mailing Address - Country:US
Mailing Address - Phone:321-727-9031
Mailing Address - Fax:321-724-8011
Practice Address - Street 1:105 S RIVERSIDE DR STE 130
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4321
Practice Address - Country:US
Practice Address - Phone:321-727-9031
Practice Address - Fax:321-724-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4374103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty