Provider Demographics
NPI:1346532249
Name:IACOVELLI, ANTHONY MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:IACOVELLI
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 1:380 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3222
Mailing Address - Country:US
Mailing Address - Phone:516-279-3403
Mailing Address - Fax:516-441-4270
Practice Address - Street 1:380 ROUTE 202
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3222
Practice Address - Country:US
Practice Address - Phone:516-279-3403
Practice Address - Fax:516-441-4270
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
NY020258103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent