Provider Demographics
NPI:1336604818
Name:WILLIS, MELANIE (LMSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 DUMONT AVE APT 5B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-5450
Mailing Address - Country:US
Mailing Address - Phone:917-940-9701
Mailing Address - Fax:
Practice Address - Street 1:423 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5011
Practice Address - Country:US
Practice Address - Phone:212-686-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104055-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker