Provider Demographics
NPI:1114151909
Name:CANONICO, LAUREN MICHELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:MICHELLE
Last Name:CANONICO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 UNIVERSITY PL FL 2G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4564
Mailing Address - Country:US
Mailing Address - Phone:646-470-1163
Mailing Address - Fax:
Practice Address - Street 1:80 UNIVERSITY PL FL 2G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4564
Practice Address - Country:US
Practice Address - Phone:646-470-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078111-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03723695Medicaid
NYA4000066633Medicare PIN