Basic Information
| Provider Information | |||||||||
| NPI: | 1306394184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROLLO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 W 168TH ST FL 12 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127290354 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 710 W 168TH ST FL 12 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123059758 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 023871 | NY | N | Behavioral Health & Social Service Providers | Psychologist | 103TH0100X | 023871 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TC0700X | 023871 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.