Provider Demographics
NPI:1902272057
Name:SLADE - ROBERTS, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:SLADE - ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 PARK AVE APT 17D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4559
Mailing Address - Country:US
Mailing Address - Phone:347-556-1405
Mailing Address - Fax:
Practice Address - Street 1:16101 89TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3902
Practice Address - Country:US
Practice Address - Phone:718-262-8190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities