Provider Demographics
NPI:1467972604
Name:QUILLEN, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:QUILLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1719 GRANDIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2815
Mailing Address - Country:US
Mailing Address - Phone:540-254-0346
Mailing Address - Fax:
Practice Address - Street 1:1719 GRANDIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015
Practice Address - Country:US
Practice Address - Phone:540-915-6472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
VA09040098411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical