Healthcare Provider Details

I. General information

NPI: 1629412499
Provider Name (Legal Business Name): MARIAM M MELBER BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CHESTNUT ST
LAKEWOOD NJ
08701-5894
US

IV. Provider business mailing address

40 CHESTNUT ST
LAKEWOOD NJ
08701-5894
US

V. Phone/Fax

Practice location:
  • Phone: 732-833-3723
  • Fax:
Mailing address:
  • Phone: 732-833-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1-06-3194
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: