MEDICARE: MELESSA WALTER BCBA, LBA

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	103K00000X	Behavior Analyst	001189-1	NY

General Provider Information

NPI Number	:	1629514013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELESSA WALTER BCBA, LBA

Provider Business Mailing Address
First Line	:	PO BOX 7
Second Line	:
City	:	JEFFERSONVILLE
State	:	NY
Zip	:	12748-0007
Country	:	US
Telephone Number	:	845-482-2017
Fax Number	:

Provider Business Practice Location Address
First Line	:	1970 52ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1731
Country	:	US
Telephone Number	:	718-360-9548
Fax Number	:

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

Provider Enumeration Date	:	01/10/2017
Last Update Date	:	01/10/2017

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