Provider Demographics
NPI:1821014200
Name:SALETSKY, ROBERTA (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:SALETSKY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:TANENBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-3115
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011006-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01501808Medicaid
55736PMedicare ID - Type Unspecified