Provider Demographics
NPI:1992575815
Name:EDMOND, MELANIE E
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:E
Last Name:EDMOND
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 1:50 ANDREA CT
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-7757
Mailing Address - Country:US
Mailing Address - Phone:219-476-6194
Mailing Address - Fax:
Practice Address - Street 1:1595 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2389
Practice Address - Country:US
Practice Address - Phone:219-764-4888
Practice Address - Fax:219-898-4258
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid