Provider Demographics
NPI:1396509865
Name:MELCOLM MENTAL HEALTH SERVICES, PLLC
Entity type:Organization
Organization Name:MELCOLM MENTAL HEALTH SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-502-9883
Mailing Address - Street 1:4110 OSCEOLA TRL
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-7149
Mailing Address - Country:US
Mailing Address - Phone:904-502-9883
Mailing Address - Fax:
Practice Address - Street 1:4110 OSCEOLA TRL
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-7149
Practice Address - Country:US
Practice Address - Phone:904-502-9883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty