Provider Demographics
NPI:1376324640
Name:MELINDA IKETAU
Entity Type:Organization
Organization Name:MELINDA IKETAU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC, PLAY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:IKETAU
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:315-922-3100
Mailing Address - Street 1:230 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3996
Mailing Address - Country:US
Mailing Address - Phone:315-922-3100
Mailing Address - Fax:
Practice Address - Street 1:230 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3996
Practice Address - Country:US
Practice Address - Phone:315-922-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty