Provider Demographics
NPI:1043672405
Name:SILLIMAN, MELINDA ANNE (QMHS)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANNE
Last Name:SILLIMAN
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:ANN
Other - Last Name:WIRTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHS
Mailing Address - Street 1:246 NORTHLAND DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3440
Mailing Address - Country:US
Mailing Address - Phone:330-725-9195
Mailing Address - Fax:330-725-9187
Practice Address - Street 1:246 NORTHLAND DR STE 200A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3440
Practice Address - Country:US
Practice Address - Phone:330-725-9195
Practice Address - Fax:330-725-9187
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$OtherSOCIAL SECURITY NUMBER