Healthcare Provider Details

I. General information

NPI: 1144232885
Provider Name (Legal Business Name): JEFF NEAL MELVIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 09/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13670 METROPOLIS AVE SUITE 101
FORT MYERS FL
33912-4346
US

IV. Provider business mailing address

13670 METROPOLIS AVE SUITE 100
FORT MYERS FL
33912-4346
US

V. Phone/Fax

Practice location:
  • Phone: 239-910-1534
  • Fax:
Mailing address:
  • Phone: 239-910-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY9023
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: