Healthcare Provider Details

I. General information

NPI: 1669495974
Provider Name (Legal Business Name): RANDALL R MELVIN LCSW BCD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 CONGRESS ST SUITE 700
PORTLAND ME
04101-3528
US

IV. Provider business mailing address

465 CONGRESS ST SUITE 700
PORTLAND ME
04101-3528
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-2828
  • Fax: 207-761-8150
Mailing address:
  • Phone: 207-773-2828
  • Fax: 207-761-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC4787
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: