Provider Demographics
NPI:1619909108
Name:AMICK, MELISSA M (PHD)
Entity Type:Individual
Prefix:PROF
First Name:MELISSA
Middle Name:M
Last Name:AMICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEMORIAL HOSPITAL OF RHODE ISLAND
Mailing Address - Street 2:111 BREWSTER STREET
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-729-3163
Mailing Address - Fax:401-729-2243
Practice Address - Street 1:MEMORIAL HOSPITAL OF RHODE ISLAND
Practice Address - Street 2:111 BREWSTER STREET
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-729-2326
Practice Address - Fax:401-729-2243
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00863103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412432OtherBLUECHIP NUMBER
RI29362-4OtherBLUE CROSS NUMBER
RI29362-4OtherBLUE CROSS NUMBER
RI007057175Medicare PIN