Provider Demographics
NPI:1225158306
Name:LIDDERDALE, MELISSA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:LIDDERDALE
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 1:57 COURTLAND ST UNIT 794
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1455
Mailing Address - Country:US
Mailing Address - Phone:616-426-9193
Mailing Address - Fax:
Practice Address - Street 1:668 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8219
Practice Address - Country:US
Practice Address - Phone:616-426-9193
Practice Address - Fax:616-426-9455
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014348103T00000X, 103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling