Provider Demographics
NPI:1205129251
Name:MELKONIAN, GWEN DEBORAH (CMT, LMT, NMT)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:DEBORAH
Last Name:MELKONIAN
Suffix:
Gender:F
Credentials:CMT, LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5975 ROSWELL RD NE STE C-333
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4048
Mailing Address - Country:US
Mailing Address - Phone:404-303-9153
Mailing Address - Fax:
Practice Address - Street 1:5975 ROSWELL RD NE STE C-333
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4048
Practice Address - Country:US
Practice Address - Phone:404-303-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA271178999OtherTIN