Provider Demographics
NPI:1861007130
Name:MANDELBAUM, MELYSSA MERA
Entity Type:Individual
Prefix:
First Name:MELYSSA
Middle Name:MERA
Last Name:MANDELBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELYSSA
Other - Middle Name:MERA
Other - Last Name:LUXENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13-47 COMERFORD PL
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5103
Mailing Address - Country:US
Mailing Address - Phone:973-997-6679
Mailing Address - Fax:
Practice Address - Street 1:13-47 COMERFORD PL
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5103
Practice Address - Country:US
Practice Address - Phone:973-997-6679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-13
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025742103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical