Provider Demographics
NPI:1255611398
Name:MELDER, MARY JO
Entity type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:MELDER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARY JO
Other - Middle Name:
Other - Last Name:GELON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:1143 ELLIOT DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3002
Mailing Address - Country:US
Mailing Address - Phone:219-616-3628
Mailing Address - Fax:
Practice Address - Street 1:1143 ELLIOT DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3002
Practice Address - Country:US
Practice Address - Phone:219-616-3628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN995922103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool