Provider Demographics
NPI:1073387056
Name:CANCELMO, LEO (PHD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:CANCELMO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 WEST END AVENUE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:243 WEST END AVENUE
Practice Address - Street 2:SUITE #101
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:917-740-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026112103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist