Provider Demographics
NPI:1023183738
Name:IANUZZI, CARLENE J (PHD)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:J
Last Name:IANUZZI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1545
Mailing Address - Country:US
Mailing Address - Phone:607-323-4110
Mailing Address - Fax:607-323-4109
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1545
Practice Address - Country:US
Practice Address - Phone:607-323-4110
Practice Address - Fax:607-323-4109
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013995103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02046142Medicaid
NY02046142Medicaid