MEDICARE: MELINDA IKETAU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1376324640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELINDA IKETAU

Provider Business Mailing Address
First Line	:	230 FRANKLIN ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-3996
Country	:	US
Telephone Number	:	315-922-3100
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 FRANKLIN ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-3996
Country	:	US
Telephone Number	:	315-922-3100
Fax Number	:

Authorized Official
Title or Position	:	LMHC, PLAY THERAPIST
Name	:	MELINDA IKETAU
Credential	:	LMHC
Telephone Number	:	315-922-3100

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/11/2023

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Directions to “MELINDA IKETAU ” Practice Location

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