Provider Demographics
NPI:1316017528
Name:MEDALIA, ALICE A (PHD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:A
Last Name:MEDALIA
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 1:6 CLUBWAY
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-3615
Mailing Address - Country:US
Mailing Address - Phone:718-920-7311
Mailing Address - Fax:718-405-0401
Practice Address - Street 1:MMC - DEPT. OF PSYCHIATRY
Practice Address - Street 2:111 EAST 210TH STREET, KLAU 2
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007362103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist