Provider Demographics
NPI:1235429168
Name:WEATHERS, MELISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WEATHERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 S 1325 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8054
Mailing Address - Country:US
Mailing Address - Phone:801-510-5756
Mailing Address - Fax:
Practice Address - Street 1:3013 S 1325 W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8054
Practice Address - Country:US
Practice Address - Phone:801-510-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7196782-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical