Provider Demographics
NPI:1861569477
Name:TIAGO DE MELO, JANINE ALIYA (PHD)
Entity type:Individual
Prefix:DR
First Name:JANINE
Middle Name:ALIYA
Last Name:TIAGO DE MELO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JANINE
Other - Middle Name:A
Other - Last Name:TIAGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:51 SEVENTH AVE SOUTH
Mailing Address - Street 2:APT 5C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014
Mailing Address - Country:US
Mailing Address - Phone:212-366-9349
Mailing Address - Fax:
Practice Address - Street 1:1651 THIRD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128
Practice Address - Country:US
Practice Address - Phone:212-427-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0139751103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02151206Medicaid
NY02151206Medicaid