Provider Demographics
NPI:1053824854
Name:MELCHING, THERESA ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ROSE
Last Name:MELCHING
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ROSE
Other - Last Name:MELCHING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1101 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5904
Mailing Address - Country:US
Mailing Address - Phone:616-456-6571
Mailing Address - Fax:616-235-0979
Practice Address - Street 1:1101 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-558-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010897791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical