Provider Demographics
NPI:1730454679
Name:DECLUE, MELINDA E (BCABA)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:E
Last Name:DECLUE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:MISS
Other - First Name:MELINDA
Other - Middle Name:E
Other - Last Name:HABERBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9811 LAKEFORD LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6229
Mailing Address - Country:US
Mailing Address - Phone:314-631-2032
Mailing Address - Fax:
Practice Address - Street 1:2560 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2417
Practice Address - Country:US
Practice Address - Phone:314-715-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011041437103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst