Provider Demographics
NPI:1376947713
Name:MELTON, IAN (BCBA)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:MELTON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E FIRMIN STREET
Mailing Address - Street 2:SUITE 209
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-2375
Mailing Address - Country:US
Mailing Address - Phone:765-454-9748
Mailing Address - Fax:765-450-6664
Practice Address - Street 1:2012 IRONWOOD CIRCLE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1889
Practice Address - Country:US
Practice Address - Phone:855-324-0885
Practice Address - Fax:765-450-6664
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-14-10035103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-14-10035OtherBCBA CERTIFICATE