Healthcare Provider Details

I. General information

NPI: 1295358307
Provider Name (Legal Business Name): VINCENT ANTHONY MELANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 NORWOOD RD
BALTIMORE MD
21212-4101
US

IV. Provider business mailing address

5100 NORWOOD RD
BALTIMORE MD
21212-4101
US

V. Phone/Fax

Practice location:
  • Phone: 410-409-2105
  • Fax:
Mailing address:
  • Phone: 410-409-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: