Provider Demographics
NPI:1619608288
Name:BAZILLION, MELANIE LAURELLE (AAS)
Entity Type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:LAURELLE
Last Name:BAZILLION
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527
Mailing Address - Country:US
Mailing Address - Phone:508-876-3223
Mailing Address - Fax:
Practice Address - Street 1:29 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527
Practice Address - Country:US
Practice Address - Phone:508-876-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA84-3882353Medicaid