Basic Information
| Provider Information | |||||||||
| NPI: | 1154346203 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'NEILL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 271 | ||||||||
| City: | CARLE PLACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115141801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007256280 | ||||||||
| FaxNumber: | 8007256380 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 WEST COLUMBIA STREET | ||||||||
| Address2: | |||||||||
| City: | COHOES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182370904 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 014177-1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02531900 | 05 | NY | MEDICAID |