Provider Demographics
NPI:1194147132
Name:WETHERINGTON, MELISSA
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:WETHERINGTON
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 1:6010 BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-9752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6010 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234
Practice Address - Country:US
Practice Address - Phone:609-272-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1194147132Medicaid