=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225649825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELINE MARIE NASSIDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2020
-----------------------------------------------------
Last Update Date | 08/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 WASHINGTON RD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15228-1901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-343-6416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2136 CAROLINA AVE
-----------------------------------------------------
City | WEST MIFFLIN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15122-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-427-0642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS019076
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------