Provider Demographics
NPI:1265565543
Name:AVILDSEN, MELISSA (LCSW)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:AVILDSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 FORT WASHINGTON AVE
Mailing Address - Street 2:APT. 2J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3708
Mailing Address - Country:US
Mailing Address - Phone:212-568-3450
Mailing Address - Fax:
Practice Address - Street 1:171 E POST RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-4965
Practice Address - Country:US
Practice Address - Phone:914-993-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO44138-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNN7832Medicare PIN