Healthcare Provider Details

I. General information

NPI: 1306394184
Provider Name (Legal Business Name): MICHAEL CAROLLO PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W 168TH ST FL 12
NEW YORK NY
10032-3726
US

IV. Provider business mailing address

710 W 168TH ST FL 12
NEW YORK NY
10032-3726
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9758
  • Fax:
Mailing address:
  • Phone: 212-729-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number023871
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number023871
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number023871
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: