MEDICARE: MS. MELLISA ANN JEWELS M.A.

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	106H00000X	Marriage & Family Therapist	000946-1	NY

General Provider Information

NPI Number	:	1871851030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELLISA ANN JEWELS M.A.

Provider Business Mailing Address
First Line	:	18 GOOSE HILL RD
Second Line	:
City	:	COLD SPRING HARBOR
State	:	NY
Zip	:	11724-1308
Country	:	US
Telephone Number	:	631-692-9689
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 GOOSE HILL RD
Second Line	:
City	:	COLD SPRING HARBOR
State	:	NY
Zip	:	11724-1308
Country	:	US
Telephone Number	:	631-692-9689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	05/21/2012

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