Provider Demographics
NPI:1295976660
Name:CANGIALOSI, ROGER ORAZIO (LLP)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:ORAZIO
Last Name:CANGIALOSI
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 VALENTINE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4713
Mailing Address - Country:US
Mailing Address - Phone:928-377-3211
Mailing Address - Fax:
Practice Address - Street 1:960 RODEO WAY
Practice Address - Street 2:HUALAPAI HEALTH DEPARTMENT
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434
Practice Address - Country:US
Practice Address - Phone:928-769-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC01090101YA0400X
MI6301013603103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist