Provider Demographics
NPI:1952858920
Name:BACK, MELODIE (LMHC)
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:
Last Name:BACK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10504 SUTPHIN BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5022
Mailing Address - Country:US
Mailing Address - Phone:844-400-1975
Mailing Address - Fax:
Practice Address - Street 1:10504 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-5022
Practice Address - Country:US
Practice Address - Phone:844-400-1975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008743101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2997620Medicaid