Provider Demographics
NPI:1073738704
Name:VANCE-BLACKWELL, MELISSA DAWN (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DAWN
Last Name:VANCE-BLACKWELL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 WEST 10TH STREET
Mailing Address - Street 2:PSYCHIATRY SERVICE
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-988-1649
Mailing Address - Fax:
Practice Address - Street 1:1481 WEST 10TH STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33004997A104100000X
IN34005380A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker