1710078555 NPI number — DR. MELODY E MARLEY PHD, HSPP

Table of content: DR. MELODY E MARLEY PHD, HSPP (NPI 1710078555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710078555 NPI number — DR. MELODY E MARLEY PHD, HSPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARLEY
Provider First Name:
MELODY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, HSPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDGE
Provider Other First Name:
MELODY
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710078555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1810 DOGWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KOKOMO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46902-5737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-553-5691
Provider Business Mailing Address Fax Number:
765-553-5772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 DOGWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46902-5737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-553-5691
Provider Business Practice Location Address Fax Number:
765-553-5772
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  20042895A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 20042895A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: 20042895A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 20042895A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000992378 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7687958 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 537605 . This is a "VALUE OPTIONS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 567370 . This is a "VALUE OPTIONS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100124250 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350868083 . This is a "TRICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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