Provider Demographics
NPI:1942874763
Name:MELTON, MIRANDA REBECCA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:REBECCA
Last Name:MELTON
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 1:7617 CHAMPLAIN DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2677
Mailing Address - Country:US
Mailing Address - Phone:252-481-1909
Mailing Address - Fax:
Practice Address - Street 1:7617 CHAMPLAIN DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2677
Practice Address - Country:US
Practice Address - Phone:252-481-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1144156103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty