Provider Demographics
NPI:1619442944
Name:WALT, MELISSA MARIE (PSYD)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MARIE
Last Name:WALT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 GOLD CREST DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-4106
Mailing Address - Country:US
Mailing Address - Phone:330-635-3801
Mailing Address - Fax:
Practice Address - Street 1:323 S COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3715
Practice Address - Country:US
Practice Address - Phone:330-331-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801520101YM0800X
OHP.07896103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health