Provider Demographics
NPI:1821638081
Name:SELPH, MELISSA ANN (MHC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:SELPH
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6712 70TH AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-6632
Mailing Address - Country:US
Mailing Address - Phone:718-781-6171
Mailing Address - Fax:
Practice Address - Street 1:6317 METROPOLITAN AVE # B
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-1634
Practice Address - Country:US
Practice Address - Phone:718-781-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health