Provider Demographics
NPI:1811632052
Name:MARTIN, MELISSA GRACE (BCBA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:GRACE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 E EVANS AVE STE 1-400
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5415
Mailing Address - Country:US
Mailing Address - Phone:720-646-1365
Mailing Address - Fax:
Practice Address - Street 1:6000 E EVANS AVE STE 1-400
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5415
Practice Address - Country:US
Practice Address - Phone:720-646-1365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-108477106S00000X
COBACB546233103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58474552Medicaid