Provider Demographics
NPI:1760836225
Name:WILSON, MELODY (LPC)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4056 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3403
Mailing Address - Country:US
Mailing Address - Phone:724-981-5433
Mailing Address - Fax:724-981-5432
Practice Address - Street 1:4056 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3403
Practice Address - Country:US
Practice Address - Phone:724-981-5433
Practice Address - Fax:724-981-5432
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008906101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health