Provider Demographics
NPI:1396365508
Name:CANTIELLO, KRYSTYNA MARY
Entity Type:Individual
Prefix:
First Name:KRYSTYNA
Middle Name:MARY
Last Name:CANTIELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-0456
Mailing Address - Country:US
Mailing Address - Phone:631-681-7120
Mailing Address - Fax:
Practice Address - Street 1:616 MOUNTAIN VIEW WAY
Practice Address - Street 2:
Practice Address - City:BUSHKILL
Practice Address - State:PA
Practice Address - Zip Code:18324-7502
Practice Address - Country:US
Practice Address - Phone:631-681-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP100223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health