Provider Demographics
NPI:1962055483
Name:MELENDEZ, KIM M
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:MELENDEZ
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 1:12360 83RD AVE APT PHC
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3452
Mailing Address - Country:US
Mailing Address - Phone:917-723-4651
Mailing Address - Fax:
Practice Address - Street 1:11655 QUEENS BLVD STE 216
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6527
Practice Address - Country:US
Practice Address - Phone:917-723-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098369104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker