Provider Demographics
NPI:1376823757
Name:WELLER, MELISSA (PSYD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FORT HILL AVE
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1159
Mailing Address - Country:US
Mailing Address - Phone:585-353-3952
Mailing Address - Fax:
Practice Address - Street 1:400 FORT HILL AVE
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1159
Practice Address - Country:US
Practice Address - Phone:585-353-3952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020817103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical