Provider Demographics
NPI:1104446202
Name:HARPER, MELANIE STREET
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:STREET
Last Name:HARPER
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 1:1008 STERLING PT
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3600
Mailing Address - Country:US
Mailing Address - Phone:678-490-1048
Mailing Address - Fax:
Practice Address - Street 1:360 STONEWALL AVE W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1547
Practice Address - Country:US
Practice Address - Phone:678-271-2107
Practice Address - Fax:770-683-1991
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-20-46012103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003218736AMedicaid
GA003243127BMedicaid