Provider Demographics
NPI:1932342755
Name:AUDIGE-PERKINS, MELISSA SMITH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:SMITH
Last Name:AUDIGE-PERKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 S BROADWAY
Mailing Address - Street 2:P.O. BOX 64
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3872
Mailing Address - Country:US
Mailing Address - Phone:845-825-0490
Mailing Address - Fax:
Practice Address - Street 1:1 S BROADWAY
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3133
Practice Address - Country:US
Practice Address - Phone:845-825-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0764151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300000677OtherMEDICARE (PTAN)