Provider Demographics
NPI:1346765609
Name:LONG, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:LONG
Other - Last Name:MILAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1410 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-6302
Mailing Address - Country:US
Mailing Address - Phone:214-650-6708
Mailing Address - Fax:972-424-2333
Practice Address - Street 1:1410 14TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6302
Practice Address - Country:US
Practice Address - Phone:214-650-6708
Practice Address - Fax:972-424-2333
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-38013103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst