Provider Demographics
NPI:1013339639
Name:DOORNEK, MELISSA ROTH (BCBA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROTH
Last Name:DOORNEK
Suffix:
Gender:F
Credentials:BCBA
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Mailing Address - Street 1:304 REEDS DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3522
Mailing Address - Country:US
Mailing Address - Phone:414-588-4427
Mailing Address - Fax:414-963-5950
Practice Address - Street 1:3215 GOLF RD STE 117
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2157
Practice Address - Country:US
Practice Address - Phone:262-672-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-17-25167OtherBEHAVIOR ANALYST CERTIFICATION BOARD
WI178-140OtherSTATE OF WISCONSIN