Provider Demographics
NPI:1235204678
Name:CHIARELLO, MICHAEL ANTHONY (PHD, NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CHIARELLO
Suffix:
Gender:M
Credentials:PHD, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 NESCONSET HWY STE 212
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1154
Mailing Address - Country:US
Mailing Address - Phone:631-689-5390
Mailing Address - Fax:631-689-5395
Practice Address - Street 1:3771 NESCONSET HWY STE 212
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-689-5390
Practice Address - Fax:631-883-6652
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400066-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02168454Medicaid
NY2E3021Medicare PIN
P35142Medicare UPIN