Provider Demographics
NPI:1679619159
Name:MELNICK, BARRY (PHD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:MELNICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2973
Mailing Address - Country:US
Mailing Address - Phone:617-969-1137
Mailing Address - Fax:
Practice Address - Street 1:100 LEDGEWOOD PL
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-1075
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:781-871-5973
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1490103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01723Medicare ID - Type Unspecified