Provider Demographics
NPI:1144566126
Name:CANCELMO, JOSEPH A (PSYD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:CANCELMO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 W END AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3615
Mailing Address - Country:US
Mailing Address - Phone:212-724-7872
Mailing Address - Fax:
Practice Address - Street 1:243 W END AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3615
Practice Address - Country:US
Practice Address - Phone:212-724-7872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008881-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical