Provider Demographics
NPI:1619653581
Name:MELO, KRISTAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTAN
Middle Name:
Last Name:MELO
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 1:110 JERICHO TPKE STE 212
Mailing Address - Street 2:
Mailing Address - City:FLORAL
Mailing Address - State:NY
Mailing Address - Zip Code:11001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 JERICHO TPKE STE 212
Practice Address - Street 2:
Practice Address - City:FLORAL
Practice Address - State:NY
Practice Address - Zip Code:11001
Practice Address - Country:US
Practice Address - Phone:347-921-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023212103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent