Provider Demographics
NPI:1013538834
Name:BLACK, MELISSA MARGO (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARGO
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 COWLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-4012
Mailing Address - Country:US
Mailing Address - Phone:517-897-2774
Mailing Address - Fax:
Practice Address - Street 1:3475 BELLE CHASE WAY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4252
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292407163WP0807X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent