Provider Demographics
NPI:1508474669
Name:IZZO, GENEVIEVE NICOLE (PHD)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:NICOLE
Last Name:IZZO
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 1:1111 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1716
Mailing Address - Country:US
Mailing Address - Phone:212-523-3067
Mailing Address - Fax:
Practice Address - Street 1:411 W 114TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1710
Practice Address - Country:US
Practice Address - Phone:212-235-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical