Provider Demographics
NPI:1710367891
Name:IKETAU, MELINDA (LMHC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:IKETAU
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8502B MCHENRY LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-2036
Mailing Address - Country:US
Mailing Address - Phone:315-806-0684
Mailing Address - Fax:
Practice Address - Street 1:230 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3996
Practice Address - Country:US
Practice Address - Phone:315-922-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP96969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health