=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417290875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MICHAEL RACANELLO PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2013
-----------------------------------------------------
Last Update Date | 10/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 635 W 165TH ST FL 6 COLUMBIA UNIVERSITY MEDICAL CENTER-NYPH
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-317-6305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 RICE AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-986-3130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 68 020777
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------