Provider Demographics
NPI:1376691469
Name:IACCINO, WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:IACCINO
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 1:2483 FREEPORT ST
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4526
Mailing Address - Country:US
Mailing Address - Phone:631-943-5493
Mailing Address - Fax:
Practice Address - Street 1:74 FIRE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3531
Practice Address - Country:US
Practice Address - Phone:631-943-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300017342Medicare PIN