Provider Demographics
NPI:1386426260
Name:ALFONSO, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ALFONSO
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 1:3 VILLAGE LN APT 23A
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-2817
Mailing Address - Country:US
Mailing Address - Phone:978-590-3293
Mailing Address - Fax:
Practice Address - Street 1:126 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4991
Practice Address - Country:US
Practice Address - Phone:978-453-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist