Provider Demographics
NPI:1790271153
Name:LICATESE, MELANIE LYNN (MSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:LYNN
Last Name:LICATESE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 GARDENIER RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-5739
Mailing Address - Country:US
Mailing Address - Phone:315-806-5085
Mailing Address - Fax:
Practice Address - Street 1:98 N 2ND ST STE 100
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1254
Practice Address - Country:US
Practice Address - Phone:315-326-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker