Healthcare Provider Details

I. General information

NPI: 1619547585
Provider Name (Legal Business Name): DREW MELESKY MA, TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 WOODWARD AVE FL 2
DETROIT MI
48201-2027
US

IV. Provider business mailing address

30346 SOUTHFIELD RD
SOUTHFIELD MI
48076-1353
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone: 586-201-4127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009321
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSP0000001035969
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: