Basic Information
| Provider Information | |||||||||
| NPI: | 1508355082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SILVA | ||||||||
| FirstName: | ADRIANA | ||||||||
| MiddleName: | MELISSA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SILVA-MADLON | ||||||||
| OtherFirstName: | ADRIANA | ||||||||
| OtherMiddleName: | MELISSA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 36 OWENS ST | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117176618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318357641 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 320 CARLETON AVE | ||||||||
| Address2: | |||||||||
| City: | CENTRAL ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117224506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316634310 | ||||||||
| FaxNumber: | 6314394066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2018 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X | 100995 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
ID Information
| ID | Type | State | Issuer | Description | 1528093242 | 05 | NY | MEDICAID |