Provider Demographics
NPI:1366693541
Name:CANCELLIERI, MICHAEL ANTHONY (BA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CANCELLIERI
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HARRISON ST
Mailing Address - Street 2:APARTMENT B
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3850
Mailing Address - Country:US
Mailing Address - Phone:603-289-6810
Mailing Address - Fax:
Practice Address - Street 1:17 93RD ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3748
Practice Address - Country:US
Practice Address - Phone:603-357-5270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health