Healthcare Provider Details

I. General information

NPI: 1053989368
Provider Name (Legal Business Name): ASHLEY M CANNIZZARO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MAIN ST STE 304
BABYLON NY
11702-3009
US

IV. Provider business mailing address

73 HEMLOCK ST
SELDEN NY
11784-1327
US

V. Phone/Fax

Practice location:
  • Phone: 631-403-4719
  • Fax:
Mailing address:
  • Phone: 631-766-6924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018260
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: