Provider Demographics
NPI:1700493103
Name:IACOVISSI, TINA (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:IACOVISSI
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ALKIRA MARRIAGE AND FAMILY THERAPY
Mailing Address - Street 2:6700 KIRKVILLE RD
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13507
Mailing Address - Country:US
Mailing Address - Phone:315-492-1390
Mailing Address - Fax:
Practice Address - Street 1:6700 KIRKVILLE RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9305
Practice Address - Country:US
Practice Address - Phone:315-492-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty