Provider Demographics
NPI:1174978159
Name:MELILLO, MARK (MS, LCADC, RYT-200)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MELILLO
Suffix:
Gender:M
Credentials:MS, LCADC, RYT-200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LINCOLN PL
Mailing Address - Street 2:D
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-4014
Mailing Address - Country:US
Mailing Address - Phone:732-331-7796
Mailing Address - Fax:
Practice Address - Street 1:1 MONUMENT DRIVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-4014
Practice Address - Country:US
Practice Address - Phone:609-924-8018
Practice Address - Fax:609-688-2045
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00252200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1174978159Medicaid
NJ1174978159Medicare NSC