Provider Demographics
NPI:1629514013
Name:WALTER, MELESSA (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MELESSA
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12748-0007
Mailing Address - Country:US
Mailing Address - Phone:845-482-2017
Mailing Address - Fax:
Practice Address - Street 1:1970 52ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1731
Practice Address - Country:US
Practice Address - Phone:718-360-9548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001189-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst