Provider Demographics
NPI:1316181886
Name:VIVINO, MELISSA ANGELA (PHD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANGELA
Last Name:VIVINO
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 1:915 W END AVE
Mailing Address - Street 2:APT 6F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3535
Mailing Address - Country:US
Mailing Address - Phone:516-521-3940
Mailing Address - Fax:
Practice Address - Street 1:915 W END AVE
Practice Address - Street 2:APT 6F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3535
Practice Address - Country:US
Practice Address - Phone:516-521-3940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012964103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical