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General NPI Number Information
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NPI Number | 1376324640
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Entity Type | Organization
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Legal Business Name | MELINDA IKETAU
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Dates
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Enumeration Date | 10/11/2023
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 230 FRANKLIN ST
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City | WATERTOWN
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State | NY
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Zip | 13601-3996
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Country | US
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Telephone | 315-922-3100
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Fax |
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Provider Business Mailing Address
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Address Line | 230 FRANKLIN ST
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City | WATERTOWN
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State | NY
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Zip | 13601-3996
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Country | US
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Telephone | 315-922-3100
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Fax |
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Authorized Official
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Title or Position | LMHC, PLAY THERAPIST
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Name | MELINDA IKETAU
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Credential | LMHC
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Telephone | 315-922-3100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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