Healthcare Provider Details

I. General information

NPI: 1053026013
Provider Name (Legal Business Name): TARA MELVIN JR. MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11315 CORPORATE BLVD STE 105
ORLANDO FL
32817-8340
US

IV. Provider business mailing address

11315 CORPORATE BLVD STE 105
ORLANDO FL
32817-8340
US

V. Phone/Fax

Practice location:
  • Phone: 407-534-0186
  • Fax:
Mailing address:
  • Phone: 407-534-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH23504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: