Provider Demographics
NPI:1639842040
Name:SMITH, MELINDA FOX (MCAP, MAC)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:FOX
Last Name:SMITH
Suffix:
Gender:F
Credentials:MCAP, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9721 THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-3811
Mailing Address - Country:US
Mailing Address - Phone:603-568-2100
Mailing Address - Fax:
Practice Address - Street 1:319 BLUE SAGE RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-4701
Practice Address - Country:US
Practice Address - Phone:603-568-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-011996-2015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)