Healthcare Provider Details

I. General information

NPI: 1700262243
Provider Name (Legal Business Name): ROBERT PAUL CARNICELLA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 STRAWBERRY AVE
LEWISTON ME
04240-5952
US

IV. Provider business mailing address

72 STRAWBERRY AVE
LEWISTON ME
04240-5952
US

V. Phone/Fax

Practice location:
  • Phone: 207-782-2150
  • Fax:
Mailing address:
  • Phone: 207-782-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS 1448
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS 1448
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: