Provider Demographics
NPI:1336759885
Name:RISTA, MELANIE ROSE (LSW)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:ROSE
Last Name:RISTA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WHITE OAK TER
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2113
Mailing Address - Country:US
Mailing Address - Phone:551-689-8440
Mailing Address - Fax:
Practice Address - Street 1:625 N MAPLE AVE STE 2
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1590
Practice Address - Country:US
Practice Address - Phone:551-264-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker