Provider Demographics
NPI:1730417957
Name:WIGHT, MELISSA L
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:L
Last Name:WIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 WEEKS RD
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-6275
Mailing Address - Country:US
Mailing Address - Phone:207-582-1285
Mailing Address - Fax:
Practice Address - Street 1:73 WEEKS RD
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-6275
Practice Address - Country:US
Practice Address - Phone:207-582-1285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-29
Last Update Date:2009-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities