Provider Demographics
NPI:1205405578
Name:WILTSHIRE, MELIZE
Entity Type:Individual
Prefix:
First Name:MELIZE
Middle Name:
Last Name:WILTSHIRE
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 1:21940 143RD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-3113
Mailing Address - Country:US
Mailing Address - Phone:929-278-0470
Mailing Address - Fax:
Practice Address - Street 1:535 FLUSHING AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-1610
Practice Address - Country:US
Practice Address - Phone:929-800-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY630152936OtherMETRO PLUS HEALTH PLAN