Provider Demographics
NPI:1689615189
Name:KIPP, MELODY LANE (PHD)
Entity type:Individual
Prefix:DR
First Name:MELODY
Middle Name:LANE
Last Name:KIPP
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 HILLSDALE LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7562
Mailing Address - Country:US
Mailing Address - Phone:407-530-5911
Mailing Address - Fax:888-216-6045
Practice Address - Street 1:3206 HILLSDALE LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7562
Practice Address - Country:US
Practice Address - Phone:407-530-5911
Practice Address - Fax:888-216-6045
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766636300Medicaid
FL766636300Medicaid