Provider Demographics
NPI:1972636967
Name:CANNIZZARO, MICHAEL S (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:CANNIZZARO
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 1:489 MAIN STREET
Mailing Address - Street 2:UNIVERSITY OF VERMONT POMEROY HALL
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05405-0130
Mailing Address - Country:US
Mailing Address - Phone:802-656-3861
Mailing Address - Fax:802-656-2528
Practice Address - Street 1:489 MAIN STREET
Practice Address - Street 2:UNIVERSITY OF VERMONT POMEROY HALL
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-0130
Practice Address - Country:US
Practice Address - Phone:802-656-3861
Practice Address - Fax:802-656-2528
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002958235Z00000X
1202944235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00069242OtherBLUE CROSS BLUE SHIELD
4148154OtherMVP