Provider Demographics
NPI:1114221702
Name:CARLISLE, MELISSA ANNE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 RIVER LODGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-1349
Mailing Address - Country:US
Mailing Address - Phone:406-750-3648
Mailing Address - Fax:
Practice Address - Street 1:7381 PRAIRIE FALCON RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0811
Practice Address - Country:US
Practice Address - Phone:702-646-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 225400000X
COCSW.099251401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner