Melina Marie Sample, PHD, HSPP

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

20043242A Issued in IN

Practice address

210 S Race St
Mishawaka, IN 46544-2032

Phone

(574) 404-6755

Fax

(833) 783-4269

NPI assigned

Aug 19, 2019

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1566172800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1566172800000",
    "number": "1861049595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2709 BLACKTAIL CT",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466149168",
            "telephone_number": "574-274-8193",
            "fax_number": "833-783-4269"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "210 S RACE ST",
            "city": "MISHAWAKA",
            "state": "IN",
            "postal_code": "465442032",
            "telephone_number": "574-404-6755",
            "fax_number": "833-783-4269"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SAMPLE",
        "first_name": "MELINA",
        "middle_name": "MARIE",
        "credential": "PHD, HSPP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2019-08-19",
        "last_updated": "2019-08-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IN",
            "license": "20043242A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "info@michiananeurosceince.co",
            "affiliation": "N",
            "endpointDescription": "Office",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "210 S Race St",
            "city": "Mishawaka",
            "state": "IN",
            "country_code": "US",
            "postal_code": "465442032",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Clinical Psychologist in Mishawaka, IN
• Providers in Mishawaka, IN by specialty
• Clinical Psychologist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.