Provider Demographics
NPI:1225167984
Name:MELILLO, ANTHONY MARK (MSW,LICSW)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MARK
Last Name:MELILLO
Suffix:
Gender:M
Credentials:MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BRADLEY STREET
Mailing Address - Street 2:ANTHONY M MELILLO
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247
Mailing Address - Country:US
Mailing Address - Phone:413-446-4210
Mailing Address - Fax:
Practice Address - Street 1:504 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2111
Practice Address - Country:US
Practice Address - Phone:413-446-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00010101041C0700X
MA10246251041C0700X
WI04-PE-AOOOAJ91041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011283Medicaid
VTCBH1057539OtherCIGNA BEHAVIORAL HEALTH
VTCBH1057539OtherCIGNA BEHAVIORAL HEALTH