Provider Demographics
NPI:1730844044
Name:STICKLE, MELISSA (LCSW R)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:STICKLE
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MONGAUP VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12762-0306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 COMMUNITY LN
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2851
Practice Address - Country:US
Practice Address - Phone:845-807-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072915101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health