Provider Demographics
NPI:1134465578
Name:DOLE, TIA R (PHD)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:R
Last Name:DOLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W. 114TH STREET
Mailing Address - Street 2:SUITE 4 A/B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025
Mailing Address - Country:US
Mailing Address - Phone:212-523-4061
Mailing Address - Fax:212-523-4911
Practice Address - Street 1:411 W. 114TH STREET
Practice Address - Street 2:SUITE 4 A/B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025
Practice Address - Country:US
Practice Address - Phone:212-523-4061
Practice Address - Fax:212-523-4911
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019906103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist