Provider Demographics
NPI:1386909695
Name:IPPOLITO, JANINE MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:MARIE
Last Name:IPPOLITO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 QUENTIN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4231
Mailing Address - Country:US
Mailing Address - Phone:800-272-3243
Mailing Address - Fax:718-854-8308
Practice Address - Street 1:3512 QUENTIN RD STE 110
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4231
Practice Address - Country:US
Practice Address - Phone:800-272-3243
Practice Address - Fax:718-854-8308
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019631103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical