Provider Demographics
NPI:1790801199
Name:MILDE, MELANIE H (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:H
Last Name:MILDE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 LINDENT STREET
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482
Mailing Address - Country:US
Mailing Address - Phone:617-291-1461
Mailing Address - Fax:781-235-0713
Practice Address - Street 1:148 LINDEN ST STE 108
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-7916
Practice Address - Country:US
Practice Address - Phone:178-189-4432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2134201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0021195802Medicare UPIN