Basic Information
| Provider Information | |||||||||
| NPI: | 1710078555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARLEY | ||||||||
| FirstName: | MELODY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, HSPP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDGE | ||||||||
| OtherFirstName: | MELODY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516556 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20042895A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0100X | 20042895A | IN | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103T00000X | 20042895A | IN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC1900X | 20042895A | IN | N | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 7687958 | 01 | IN | AETNA | OTHER | 537605 | 01 | IN | VALUE OPTIONS | OTHER | 567370 | 01 | IN | VALUE OPTIONS | OTHER | 000000992378 | 01 | IN | ANTHEM BC/BS | OTHER | 100124250 | 05 | IN | MEDICAID | 350868083 | 01 | IN | TRICARE | OTHER |