Provider Demographics
NPI:1689774614
Name:MASIELLO, GREGORY JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:MASIELLO
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 1:6 JOHNNY PL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-2028
Mailing Address - Country:US
Mailing Address - Phone:518-477-9413
Mailing Address - Fax:
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-5392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 015100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist