Provider Demographics
NPI:1184638587
Name:SIMON, MELINDA J (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:J
Last Name:SIMON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 W ST JOE HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4093
Mailing Address - Country:US
Mailing Address - Phone:517-323-4099
Mailing Address - Fax:513-323-3334
Practice Address - Street 1:5123 W ST JOE HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4093
Practice Address - Country:US
Practice Address - Phone:517-323-4099
Practice Address - Fax:513-323-3334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009976103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680B345180OtherBCBS
MI0N20690Medicare PIN
S44831Medicare UPIN