Provider Demographics
NPI:1265801831
Name:TART, MELISSA LORAE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LORAE
Last Name:TART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LORAE
Other - Last Name:RHODES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 ONEILL AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6826
Mailing Address - Country:US
Mailing Address - Phone:347-683-1789
Mailing Address - Fax:
Practice Address - Street 1:30 ONEILL AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6826
Practice Address - Country:US
Practice Address - Phone:347-683-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1217065103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst