Provider Demographics
NPI:1902192685
Name:CANNATA, MICHELE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:CANNATA
Suffix:
Gender:F
Credentials:PSYD
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 30
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825-0030
Mailing Address - Country:US
Mailing Address - Phone:201-410-7119
Mailing Address - Fax:
Practice Address - Street 1:1247 SUSSEX TPKE
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2943
Practice Address - Country:US
Practice Address - Phone:201-410-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical