Provider Demographics
NPI:1740453158
Name:IACOVIELLO, BRIAN MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:IACOVIELLO
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 1:1785 AMSTERDAM AVE
Mailing Address - Street 2:APT 4F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-3550
Mailing Address - Country:US
Mailing Address - Phone:267-934-5533
Mailing Address - Fax:
Practice Address - Street 1:156 5TH AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7002
Practice Address - Country:US
Practice Address - Phone:646-719-0237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical