MEDICARE: CARLO A. GIACOMONI PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2779	WI
2	103T00000X	Psychologist	5506	MN

General Provider Information

NPI Number	:	1104061902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLO A. GIACOMONI PSYD

Provider Business Mailing Address
First Line	:	2984 RICE ST
Second Line	:
City	:	LITTLE CANADA
State	:	MN
Zip	:	55113-2230
Country	:	US
Telephone Number	:	651-314-4350
Fax Number	:

Provider Business Practice Location Address
First Line	:	2984 RICE ST
Second Line	:
City	:	LITTLE CANADA
State	:	MN
Zip	:	55113-2230
Country	:	US
Telephone Number	:	651-314-4350
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	10/30/2017

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