Provider Demographics
NPI:1356448054
Name:TRIEMSTRA, MELINDA S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:S
Last Name:TRIEMSTRA
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 1:3410 RANDOM RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004
Mailing Address - Country:US
Mailing Address - Phone:269-364-5302
Mailing Address - Fax:
Practice Address - Street 1:520 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1762
Practice Address - Country:US
Practice Address - Phone:269-783-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW30801041C0700X
MI6801091057104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3696505Medicare ID - Type Unspecified