MEDICARE: YEVGENIYA KUTUZOVA MELNIK PSYD

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	101Y00000X	Counselor
2	103K00000X	Behavior Analyst
3	103TC0700X	Clinical Psychologist	06053	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06053	OTHER	MD	PSYCHOLOGY LICENSE

General Provider Information

NPI Number	:	1801177068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YEVGENIYA KUTUZOVA MELNIK PSYD

Provider Business Mailing Address
First Line	:	60 MARKET ST STE 213
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-6559
Country	:	US
Telephone Number	:	240-750-6467
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 MARKET ST STE 213
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-6559
Country	:	US
Telephone Number	:	240-750-6467
Fax Number	:

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

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	03/15/2019

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