Healthcare Provider Details

I. General information

NPI: 1417724782
Provider Name (Legal Business Name): MRS. MELINDA CATHERINE KAMPNICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25801 MUSTARD RD
WATERTOWN NY
13601-5229
US

IV. Provider business mailing address

25801 MUSTARD RD
WATERTOWN NY
13601-5229
US

V. Phone/Fax

Practice location:
  • Phone: 315-955-4614
  • Fax:
Mailing address:
  • Phone: 315-955-4614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP140143
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: