Provider Demographics
NPI:1184174013
Name:WINTZ-DYKSTRA, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WINTZ-DYKSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7316 ONATE CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6349
Mailing Address - Country:US
Mailing Address - Phone:513-253-6147
Mailing Address - Fax:
Practice Address - Street 1:2300 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1851
Practice Address - Country:US
Practice Address - Phone:505-272-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-20-40546103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst