Active NPI
Michelle Fanciullo, PSY.D.
- Clinical Child & Adolescent Psychologist
- Hackensack, NJ
National Provider Identifier
1144831082
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Child & Adolescent Psychologist
- License
- 35SI00623300
- Practice address
- 12 2ND St
Hackensack, NJ 07601-2009 - Phone
- (551) 996-8186
- NPI assigned
- Aug 13, 2020
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Child & Adolescent Psychologist | 103TC2200X | 35SI00623300 | NJ | Primary |
Addresses
Primary practice location
12 2ND St
Hackensack, NJ 07601-2009
Mailing address
30 Prospect Ave
Hackensack, NJ 07601-1915
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Oct 28, 2025 through Oct 28, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 35SI00623300 | NJ | MD | Clinical Child & Adolescent Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1597276800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1597276800000",
"number": "1144831082",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "30 PROSPECT AVE",
"city": "HACKENSACK",
"state": "NJ",
"postal_code": "076011915"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12 2ND ST",
"city": "HACKENSACK",
"state": "NJ",
"postal_code": "076012009",
"telephone_number": "551-996-8186"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FANCIULLO",
"first_name": "MICHELLE",
"credential": "PSY.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2020-08-13",
"last_updated": "2020-08-13",
"certification_date": "2020-08-13",
"status": "A"
},
"taxonomies": [
{
"code": "103TC2200X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical Child & Adolescent",
"state": "NJ",
"license": "35SI00623300",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Hackensack, NJ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.