Provider Demographics
NPI:1942602487
Name:VARDON, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:VARDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 CAROL LANE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278
Mailing Address - Country:US
Mailing Address - Phone:330-633-3275
Mailing Address - Fax:
Practice Address - Street 1:196 N PROSPECT ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2281
Practice Address - Country:US
Practice Address - Phone:330-676-7409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHKU1039522103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool