Provider Demographics
NPI:1114373818
Name:SMITH, MELISSA ANNE (MA, LAC)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 S KINDERKAMACK RD
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-2128
Mailing Address - Country:US
Mailing Address - Phone:201-982-3846
Mailing Address - Fax:
Practice Address - Street 1:23 S KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-2128
Practice Address - Country:US
Practice Address - Phone:201-982-3846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00291700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional