Provider Demographics
NPI:1972667145
Name:MELILLO, PETER A (LCSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:MELILLO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 81ST ST
Mailing Address - Street 2:5D
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6969
Mailing Address - Country:US
Mailing Address - Phone:718-446-6644
Mailing Address - Fax:212-243-3175
Practice Address - Street 1:322 8TH AVE
Practice Address - Street 2:802
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-8001
Practice Address - Country:US
Practice Address - Phone:212-243-2830
Practice Address - Fax:212-243-3175
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR044108-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8772OtherUBH PAYER ID NUMBER
NY494519OtherVALUE OPTIONS PROVIDER #
NY02454108Medicaid