Provider Demographics
NPI:1063751691
Name:GABRIELLE DICANIO-KIRBY
Entity type:Organization
Organization Name:GABRIELLE DICANIO-KIRBY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SCHOOL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICANIO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:1516-319-0576
Mailing Address - Street 1:15 PEGS LN
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11724-2414
Mailing Address - Country:US
Mailing Address - Phone:516-319-0576
Mailing Address - Fax:
Practice Address - Street 1:15 PEGS LN
Practice Address - Street 2:
Practice Address - City:COLD SPRING HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11724-2414
Practice Address - Country:US
Practice Address - Phone:516-319-0576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251300000X
NY68 016934252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid