Provider Demographics
NPI:1437344967
Name:WIGFALL, MELISSA R (CASAC)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:R
Last Name:WIGFALL
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9741 109TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1012
Mailing Address - Country:US
Mailing Address - Phone:917-279-3473
Mailing Address - Fax:
Practice Address - Street 1:8956 162ND ST FL 3
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5072
Practice Address - Country:US
Practice Address - Phone:718-297-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)