Provider Demographics
NPI:1467696724
Name:NINA, CARMELO MICHAEL (PH D)
Entity Type:Individual
Prefix:DR
First Name:CARMELO
Middle Name:MICHAEL
Last Name:NINA
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2299 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3223
Mailing Address - Country:US
Mailing Address - Phone:516-426-8904
Mailing Address - Fax:
Practice Address - Street 1:2299 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-3223
Practice Address - Country:US
Practice Address - Phone:516-426-8904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017821103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017821OtherPSYCHOLOGIST LICENSE