Provider Demographics
NPI:1982212890
Name:BLACK, MELANIE P
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:P
Last Name:BLACK
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:PO BOX 1062
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19001-9062
Mailing Address - Country:US
Mailing Address - Phone:215-285-3688
Mailing Address - Fax:215-469-4987
Practice Address - Street 1:2801 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:PA
Practice Address - Zip Code:19001-2242
Practice Address - Country:US
Practice Address - Phone:215-285-3688
Practice Address - Fax:215-469-4987
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARBT-15-11617106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician