Provider Demographics
NPI:1891709770
Name:SIMON, MELANIE ALYSE (MSPT)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:ALYSE
Last Name:SIMON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 W 186TH ST
Mailing Address - Street 2:#5E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-2903
Mailing Address - Country:US
Mailing Address - Phone:212-740-2055
Mailing Address - Fax:
Practice Address - Street 1:630 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-3900
Practice Address - Country:US
Practice Address - Phone:212-927-3422
Practice Address - Fax:212-927-9250
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ00V21Medicare ID - Type Unspecified