=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659343846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY E CRETELLA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 10/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 243 CENTER ST
-----------------------------------------------------
City | CANANDAIGUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14424-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-424-3390
-----------------------------------------------------
Fax | 585-272-8986
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 LARCHWOOD DR
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-248-0427
-----------------------------------------------------
Fax | 585-223-9241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 130292
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 130292
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------