Provider Demographics
NPI:1265834345
Name:FORTSON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FORTSON
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 1:1032 OLD PEACHTREE RD NW STE 401
Mailing Address - Street 2:PMB 518
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3324
Mailing Address - Country:US
Mailing Address - Phone:404-654-3919
Mailing Address - Fax:
Practice Address - Street 1:1739 LEGRAND CIR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8184
Practice Address - Country:US
Practice Address - Phone:770-513-4331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-21
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst