Provider Demographics
NPI:1972387835
Name:PFENNIG, MELANIE ROSE
Entity Type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:ROSE
Last Name:PFENNIG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MELANIE
Other - Middle Name:ROSE
Other - Last Name:PFENNIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1418
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-0996
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7555 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-1516
Practice Address - Country:US
Practice Address - Phone:631-298-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker