Provider Demographics
NPI:1174822811
Name:AGEE-MARES, MELYSSA PEARL (LMSW)
Entity Type:Individual
Prefix:
First Name:MELYSSA
Middle Name:PEARL
Last Name:AGEE-MARES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 RED CANYON RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-2577
Mailing Address - Country:US
Mailing Address - Phone:505-514-6640
Mailing Address - Fax:
Practice Address - Street 1:1005 21ST ST SE
Practice Address - Street 2:STE B
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4030
Practice Address - Country:US
Practice Address - Phone:505-990-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-086011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty