Provider Demographics
NPI:1083091870
Name:KANELLOPOULOS, THEODORA (PHD)
Entity Type:Individual
Prefix:DR
First Name:THEODORA
Middle Name:
Last Name:KANELLOPOULOS
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 1:21 BLOOMINGDALE RD
Mailing Address - Street 2:7 SOUTH
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1504
Mailing Address - Country:US
Mailing Address - Phone:917-886-4779
Mailing Address - Fax:
Practice Address - Street 1:21 BLOOMINGDALE RD
Practice Address - Street 2:7 SOUTH
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1504
Practice Address - Country:US
Practice Address - Phone:917-886-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021101103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical