Provider Demographics
NPI:1417290875
Name:RACANELLO, AMY MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHAEL
Last Name:RACANELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 RICE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2509
Mailing Address - Country:US
Mailing Address - Phone:718-986-3130
Mailing Address - Fax:
Practice Address - Street 1:635 W 165TH ST FL 6
Practice Address - Street 2:COLUMBIA UNIVERSITY MEDICAL CENTER-NYPH
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3724
Practice Address - Country:US
Practice Address - Phone:646-317-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
NY68 020777103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist