Healthcare Provider Details

I. General information

NPI: 1750737151
Provider Name (Legal Business Name): MELANIE POMAVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 W MONTROSE AVE
CHICAGO IL
60634-1556
US

IV. Provider business mailing address

5875 PEACHTREE DR
GRAND LEDGE MI
48837-8908
US

V. Phone/Fax

Practice location:
  • Phone: 517-599-7422
  • Fax:
Mailing address:
  • Phone: 517-599-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-22735
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: