Provider Demographics
NPI:1861049595
Name:SAMPLE, MELINA MARIE (PHD, HSPP)
Entity type:Individual
Prefix:
First Name:MELINA
Middle Name:MARIE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 BLACKTAIL CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-9168
Mailing Address - Country:US
Mailing Address - Phone:574-274-8193
Mailing Address - Fax:833-783-4269
Practice Address - Street 1:210 S RACE ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2032
Practice Address - Country:US
Practice Address - Phone:574-404-6755
Practice Address - Fax:833-783-4269
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043242A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical