Provider Demographics
NPI:1841850708
Name:MELILLO, MARINA R (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:R
Last Name:MELILLO
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MAPLECREST DR
Mailing Address - Street 2:
Mailing Address - City:N BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-1045
Mailing Address - Country:US
Mailing Address - Phone:516-672-0787
Mailing Address - Fax:
Practice Address - Street 1:305 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2102
Practice Address - Country:US
Practice Address - Phone:516-741-0729
Practice Address - Fax:516-209-4556
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001660103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst