Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 1641 | GA |
Y | 103TC0700X | Clinical Psychologist | 1641 | GA |
NPI | 1003985243 |
---|---|
Provider Name | Mary Melton |
First Address | Minneapolis, MN 55455-4800 |
Second Address | Minneapolis, MN 55455-4800 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2006 |
Last Update Date | 20/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
316698UBS | (02) | GA |