Healthcare Provider Details

I. General information

NPI: 1225129307
Provider Name (Legal Business Name): MICHAEL JOSEPH CANZONIERO PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SALTY WAY
SHOREHAM NY
11786-1146
US

IV. Provider business mailing address

4 SALTY WAY
SHOREHAM NY
11786-1146
US

V. Phone/Fax

Practice location:
  • Phone: 631-821-2773
  • Fax: 631-821-2773
Mailing address:
  • Phone: 631-821-2773
  • Fax: 631-821-2773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number006227-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: