Provider Demographics
NPI:1154096378
Name:PEDERSON, MELISSA LYNN (MA,LADC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MA,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 233
Mailing Address - Street 2:
Mailing Address - City:KNIFE RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55609-0233
Mailing Address - Country:US
Mailing Address - Phone:218-282-2174
Mailing Address - Fax:
Practice Address - Street 1:4615 GRAND AVE STE 300
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2749
Practice Address - Country:US
Practice Address - Phone:218-282-2174
Practice Address - Fax:218-600-5485
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305465101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)