Provider Demographics
NPI:1548555048
Name:ANDREA DERATANY, PSY.D., P.A.
Entity type:Organization
Organization Name:ANDREA DERATANY, PSY.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:G
Authorized Official - Last Name:DERATANY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:321-727-9031
Mailing Address - Street 1:105 S RIVERSIDE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4365
Mailing Address - Country:US
Mailing Address - Phone:321-727-9031
Mailing Address - Fax:321-724-8011
Practice Address - Street 1:105 S RIVERSIDE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4365
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:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 4374103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73749Medicare UPIN