Provider Demographics
NPI:1851129704
Name:POULIN, MELISSA M (RBT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:POULIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 RIDGEMONT RD
Mailing Address - Street 2:
Mailing Address - City:EARLYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22936-9710
Mailing Address - Country:US
Mailing Address - Phone:703-505-1728
Mailing Address - Fax:
Practice Address - Street 1:625 RIDGEMONT RD
Practice Address - Street 2:
Practice Address - City:EARLYSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22936-9710
Practice Address - Country:US
Practice Address - Phone:703-505-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23-3276-516881106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician