=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700482577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA REEDY DEAN M.ED. BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2020
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 S 6TH ST UNIT B
-----------------------------------------------------
City | WYTHEVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24382-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-782-5976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 S 6TH ST UNIT B
-----------------------------------------------------
City | WYTHEVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24382-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-782-5976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-20-46408
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------