Provider Demographics
NPI:1619608288
Name:BAZILLION, MELANIE LAURELLE (LADC 2)
Entity type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:LAURELLE
Last Name:BAZILLION
Suffix:
Gender:F
Credentials:LADC 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-2639
Mailing Address - Country:US
Mailing Address - Phone:978-727-5720
Mailing Address - Fax:
Practice Address - Street 1:133 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-2639
Practice Address - Country:US
Practice Address - Phone:978-727-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA84-3882353Medicaid