Basic Information
| Provider Information | |||||||||
| NPI: | 1376947713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELTON | ||||||||
| FirstName: | IAN | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E FIRMIN STREET | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469022375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654549748 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Practice Location | |||||||||
| Address1: | 2012 IRONWOOD CIRCLE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2014 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-10035 | MA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-14-10035 | 01 | BCBA CERTIFICATE | OTHER |