Basic Information
| Provider Information | |||||||||
| NPI: | 1750316667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | CROUCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 BARKER AVE | ||||||||
| Address2: | PARK AVENUE MEDICAL ASSOCIATES PC 4TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106011509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 BARKER AVE | ||||||||
| Address2: | PARK AVENUE MEDICAL ASSOCIATES PC 4TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106011509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 015888-1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02694457 | 05 | NY | MEDICAID |