Provider Demographics
NPI:1629213830
Name:BREWER, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 PATRONIS DR
Mailing Address - Street 2:APT. 306
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-5750
Mailing Address - Country:US
Mailing Address - Phone:850-819-3061
Mailing Address - Fax:
Practice Address - Street 1:7120 PATRONIS DR
Practice Address - Street 2:APT. 306
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408-5750
Practice Address - Country:US
Practice Address - Phone:850-819-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0-08-2472103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst