Provider Demographics
NPI:1609147990
Name:FRED, MELITZIE
Entity Type:Individual
Prefix:
First Name:MELITZIE
Middle Name:
Last Name:FRED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LOIZA VALLEY SHOPPING LOCAL AA-6
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00729
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LOIZA VALLEY SHOPPING CENTER
Practice Address - Street 2:LOCAL AA-6
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-648-4863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR191081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical