Provider Demographics
NPI:1710753009
Name:MELNIKOV, TATIANA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:MELNIKOV
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 1:1565 E 14TH ST APT 6G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7156
Mailing Address - Country:US
Mailing Address - Phone:718-708-9315
Mailing Address - Fax:
Practice Address - Street 1:1565 E 14TH ST APT 6G
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7156
Practice Address - Country:US
Practice Address - Phone:718-708-9315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1199439390200000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program