Provider Demographics
NPI:1649745977
Name:MELVIN, LORENE IZZETTA (LICSW)
Entity Type:Individual
Prefix:
First Name:LORENE
Middle Name:IZZETTA
Last Name:MELVIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BOOTLAND FARM RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NH
Mailing Address - Zip Code:03858-4019
Mailing Address - Country:US
Mailing Address - Phone:339-368-1386
Mailing Address - Fax:
Practice Address - Street 1:19 BOOTLAND FARM RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NH
Practice Address - Zip Code:03858-4019
Practice Address - Country:US
Practice Address - Phone:339-368-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1062531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical