Provider Demographics
NPI:1669759361
Name:DESMARAIS, MELINDA (BA, BCABA)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:DESMARAIS
Suffix:
Gender:F
Credentials:BA, BCABA
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 61756
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17106-1756
Mailing Address - Country:US
Mailing Address - Phone:609-306-1455
Mailing Address - Fax:
Practice Address - Street 1:1826 GREEN ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17102-2254
Practice Address - Country:US
Practice Address - Phone:609-306-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0-11-4391103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst