Provider Demographics
NPI:1336181130
Name:KMETZ, MELINDA L (BA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:L
Last Name:KMETZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:13865-0142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 HAWLEY ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-3102
Practice Address - Country:US
Practice Address - Phone:607-778-1145
Practice Address - Fax:607-778-1164
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249154Medicaid