Provider Demographics
NPI:1649254970
Name:KANARIS, PETER S (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:KANARIS
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 1:496 SMITHTOWN BYP
Mailing Address - Street 2:#304
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5005
Mailing Address - Country:US
Mailing Address - Phone:631-979-2640
Mailing Address - Fax:631-979-2684
Practice Address - Street 1:496 SMITHTOWN BYP
Practice Address - Street 2:#304
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5005
Practice Address - Country:US
Practice Address - Phone:631-979-2640
Practice Address - Fax:631-979-2684
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006658103TC0700X, 103TA0700X, 103TB0200X, 103TF0000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00600091Medicaid
NYV16332Medicare PIN