Provider Demographics
NPI:1578059887
Name:MELVIN, STEFAN TYLER
Entity Type:Individual
Prefix:MR
First Name:STEFAN
Middle Name:TYLER
Last Name:MELVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 WAKE FOREST RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6859
Mailing Address - Country:US
Mailing Address - Phone:919-865-8856
Mailing Address - Fax:
Practice Address - Street 1:1325 SOUTHPOINT CROSSING DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6608
Practice Address - Country:US
Practice Address - Phone:919-662-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0126631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical