Provider Demographics
NPI:1154638641
Name:THEM-PETERSON, MELISSA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:A
Last Name:THEM-PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:THEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1 PINE WEST PLZ
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-5531
Mailing Address - Country:US
Mailing Address - Phone:518-218-1188
Mailing Address - Fax:518-218-1988
Practice Address - Street 1:1 PINE WEST PLZ
Practice Address - Street 2:SUITE 106
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5531
Practice Address - Country:US
Practice Address - Phone:518-218-1188
Practice Address - Fax:518-218-1988
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68017899103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical