Provider Demographics
NPI:1194290080
Name:FATIGA, MELINDA
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:FATIGA
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 1:163 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1721
Mailing Address - Country:US
Mailing Address - Phone:315-592-4453
Mailing Address - Fax:
Practice Address - Street 1:163 S 1ST ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1721
Practice Address - Country:US
Practice Address - Phone:315-592-4453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP13103101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health