MEDICARE: MELISSA DERVISHIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	5878	MA

General Provider Information

NPI Number	:	1194955278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA DERVISHIAN

Provider Business Mailing Address
First Line	:	28 TORY FORT LN
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01602-1223
Country	:	US
Telephone Number	:	508-752-4109
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 TORY FORT LN
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01602-1223
Country	:	US
Telephone Number	:	508-752-4109
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2009
Last Update Date	:	07/22/2009

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Directions to “ MELISSA DERVISHIAN ” Practice Location

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