Provider Demographics
NPI:1083874671
Name:SMITH, MELISSA HANSEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:HANSEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 N STATE STREET
Mailing Address - Street 2:CENTER FOR CHANGE
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2025
Mailing Address - Country:US
Mailing Address - Phone:801-224-8255
Mailing Address - Fax:801-224-8301
Practice Address - Street 1:1790 N STATE STREET
Practice Address - Street 2:CENTER FOR CHANGE
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2025
Practice Address - Country:US
Practice Address - Phone:801-224-8255
Practice Address - Fax:801-224-8301
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63310022504103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist