MEDICARE: MELINDA IKETAU LMHC

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	P96969	NY

General Provider Information

NPI Number	:	1710367891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELINDA IKETAU LMHC

Provider Business Mailing Address
First Line	:	8502B MCHENRY LOOP
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-2036
Country	:	US
Telephone Number	:	315-806-0684
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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/14/2023

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