Provider Demographics
NPI:1366941833
Name:MELKUMOV, MELISSA ANN (PSYD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MELKUMOV
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 1:491 6TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4041
Mailing Address - Country:US
Mailing Address - Phone:734-276-5021
Mailing Address - Fax:
Practice Address - Street 1:19 WEST 34TH ST
Practice Address - Street 2:PENTHOUSE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:646-374-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022561103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist