Provider Demographics
NPI:1669495974
Name:MELVIN, RANDALL R (LCSW BCD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:MELVIN
Suffix:
Gender:M
Credentials:LCSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 CONGRESS ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3528
Mailing Address - Country:US
Mailing Address - Phone:207-773-2828
Mailing Address - Fax:207-761-8150
Practice Address - Street 1:465 CONGRESS ST
Practice Address - Street 2:SUITE 700
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3528
Practice Address - Country:US
Practice Address - Phone:207-773-2828
Practice Address - Fax:207-761-8150
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC47871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME040317OtherANTHEM BLUE CROSS
MEMM5639Medicare ID - Type Unspecified
ME040317OtherANTHEM BLUE CROSS