Provider Demographics
NPI:1942693544
Name:IACOBELLI, LINDA (MS PSYCHOLOGY)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:
Last Name:IACOBELLI
Suffix:
Gender:F
Credentials:MS PSYCHOLOGY
Other - Prefix:MS
Other - First Name:LINDA
Other - Middle Name:IACOBELLI
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:41 EVA AVE
Mailing Address - Street 2:STATEN ISLAND
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-5609
Mailing Address - Country:US
Mailing Address - Phone:646-996-1643
Mailing Address - Fax:
Practice Address - Street 1:41 EVA AVE
Practice Address - Street 2:STATEN ISLAND
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-5609
Practice Address - Country:US
Practice Address - Phone:646-996-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialist