Healthcare Provider Details

I. General information

NPI: 1144831082
Provider Name (Legal Business Name): MICHELLE FANCIULLO PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 2ND ST
HACKENSACK NJ
07601-2009
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-8186
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number35SI00623300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: