Provider Demographics
NPI:1134493257
Name:SHANK, MELANIE C
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:C
Last Name:SHANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:C
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:171 OAK SIDE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-5356
Mailing Address - Country:US
Mailing Address - Phone:860-559-8854
Mailing Address - Fax:
Practice Address - Street 1:740 E GENERAL STEWART WAY STE 103
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2636
Practice Address - Country:US
Practice Address - Phone:877-321-2899
Practice Address - Fax:877-540-0182
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-12-4479103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst