Provider Demographics
NPI:1700262243
Name:CARNICELLA, ROBERT PAUL (PHD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PAUL
Last Name:CARNICELLA
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 1:72 STRAWBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5952
Mailing Address - Country:US
Mailing Address - Phone:207-782-2150
Mailing Address - Fax:
Practice Address - Street 1:72 STRAWBERRY AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5952
Practice Address - Country:US
Practice Address - Phone:207-782-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS 1448103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent