Provider Demographics
NPI:1962658427
Name:MACDONALD, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5649
Mailing Address - Country:US
Mailing Address - Phone:848-326-1163
Mailing Address - Fax:848-326-1163
Practice Address - Street 1:3600 ROUTE 66 STE 150
Practice Address - Street 2:ROOM 140
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-2645
Practice Address - Country:US
Practice Address - Phone:848-326-1163
Practice Address - Fax:848-326-1163
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00376700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37LC00191000OtherLCADC
NJ37PC00376700OtherLPC