Healthcare Provider Details

I. General information

NPI: 1639471246
Provider Name (Legal Business Name): MELANIE DE QUADROS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 MACON RD SUITE 18
COLUMBUS GA
31907-8200
US

IV. Provider business mailing address

3575 MACON RD SUITE 18
COLUMBUS GA
31907-8200
US

V. Phone/Fax

Practice location:
  • Phone: 706-565-5927
  • Fax: 706-565-8207
Mailing address:
  • Phone: 706-565-5927
  • Fax: 706-565-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013232
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006925
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: