Provider Demographics
NPI:1699445957
Name:KWAVNICK, MELISSA ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:KWAVNICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10631 PARIS ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-4822
Mailing Address - Country:US
Mailing Address - Phone:954-465-0372
Mailing Address - Fax:
Practice Address - Street 1:2741 EXECUTIVE PARK DR STE 1
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3641
Practice Address - Country:US
Practice Address - Phone:954-385-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7648103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist