Provider Demographics
NPI:1306197868
Name:BRINN, MELISSA KATE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:KATE
Last Name:BRINN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 TULLS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-9384
Mailing Address - Country:US
Mailing Address - Phone:757-515-7985
Mailing Address - Fax:
Practice Address - Street 1:1308 TULLS CREEK RD
Practice Address - Street 2:
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-9384
Practice Address - Country:US
Practice Address - Phone:757-515-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000744103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA13808534OtherCAQH