Provider Demographics
NPI:1962607028
Name:FILL, MELODY (SW)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:FILL
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 SEVEN BAR LOOP RD NW
Mailing Address - Street 2:SEVEN BAR ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5600
Mailing Address - Country:US
Mailing Address - Phone:505-899-2797
Mailing Address - Fax:
Practice Address - Street 1:4501 SEVEN BAR LOOP RD NW
Practice Address - Street 2:SEVEN BAR ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5600
Practice Address - Country:US
Practice Address - Phone:505-899-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 25191041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNO # AT THIS TIMEOtherPROVIDER #