Provider Demographics
NPI:1881352136
Name:SAKOFSKY KANARA, MELISSA JILL
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JILL
Last Name:SAKOFSKY KANARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1361
Mailing Address - Country:US
Mailing Address - Phone:864-210-3115
Mailing Address - Fax:
Practice Address - Street 1:1627 E NORTH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1361
Practice Address - Country:US
Practice Address - Phone:864-210-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC10427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid