Provider Demographics
NPI:1881381788
Name:WANTUCH, MELODIE (BA, MCJ, CFI)
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:
Last Name:WANTUCH
Suffix:
Gender:F
Credentials:BA, MCJ, CFI
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 620515
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80162-0515
Mailing Address - Country:US
Mailing Address - Phone:720-742-0417
Mailing Address - Fax:
Practice Address - Street 1:391 PINON CIR
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:CO
Practice Address - Zip Code:80422-8892
Practice Address - Country:US
Practice Address - Phone:720-742-0417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling