Provider Demographics
NPI:1245939404
Name:UWUMWAMI, MELCHISEDECK
Entity type:Individual
Prefix:
First Name:MELCHISEDECK
Middle Name:
Last Name:UWUMWAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5639 W WALATOWA ST
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-5707
Mailing Address - Country:US
Mailing Address - Phone:872-235-5424
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE STE 1032
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6203
Practice Address - Country:US
Practice Address - Phone:872-235-5424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator