Provider Demographics
NPI:1609814524
Name:MICHELUCCI, ERNESTO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:MICHELUCCI
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 1:620 CROSSKEYS OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3508
Mailing Address - Country:US
Mailing Address - Phone:585-223-5920
Mailing Address - Fax:585-223-5727
Practice Address - Street 1:620 CROSSKEYS OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3508
Practice Address - Country:US
Practice Address - Phone:585-223-5920
Practice Address - Fax:585-223-5727
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012014103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA0194Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST