Provider Demographics
NPI:1811577257
Name:ANTOINE, MELAKU
Entity Type:Individual
Prefix:
First Name:MELAKU
Middle Name:
Last Name:ANTOINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2125
Mailing Address - Country:US
Mailing Address - Phone:267-243-0597
Mailing Address - Fax:
Practice Address - Street 1:528 ELM AVE
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2125
Practice Address - Country:US
Practice Address - Phone:267-243-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004708103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst