Provider Demographics
NPI:1467702761
Name:NYLIC, MELISSA LAUREN
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LAUREN
Last Name:NYLIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LAUREN
Other - Last Name:HEALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36 NASSAU AVENUE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:516-650-1851
Mailing Address - Fax:
Practice Address - Street 1:189 WHEATLEY ROAD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:NY
Practice Address - Zip Code:11545
Practice Address - Country:US
Practice Address - Phone:516-626-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1149323103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool