Provider Demographics
NPI:1629190525
Name:MCGULLAM, MELINDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:MCGULLAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 HOOVER DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-2712
Mailing Address - Country:US
Mailing Address - Phone:732-899-0427
Mailing Address - Fax:
Practice Address - Street 1:2095 ROUTE 88
Practice Address - Street 2:SUITE 3
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3265
Practice Address - Country:US
Practice Address - Phone:732-701-0440
Practice Address - Fax:732-701-0419
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053169001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical