Provider Demographics
NPI:1336363274
Name:CANTILENA, MARY ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:CANTILENA
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 1:157 GIFFORDS LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2012
Mailing Address - Country:US
Mailing Address - Phone:718-984-5402
Mailing Address - Fax:718-984-5402
Practice Address - Street 1:157 GIFFORDS LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2012
Practice Address - Country:US
Practice Address - Phone:718-984-5402
Practice Address - Fax:718-984-5402
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVOB621Medicare ID - Type UnspecifiedPSYCHOLOGIST