Provider Demographics
NPI:1356455083
Name:KRUSE, MELISSA DAWN (LMSW/ACSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DAWN
Last Name:KRUSE
Suffix:
Gender:F
Credentials:LMSW/ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3847 PINE GROVE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4265
Mailing Address - Country:US
Mailing Address - Phone:810-966-3533
Mailing Address - Fax:810-985-7350
Practice Address - Street 1:3847 PINE GROVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4265
Practice Address - Country:US
Practice Address - Phone:810-966-3533
Practice Address - Fax:810-985-7350
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010782991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801078299Medicare ID - Type UnspecifiedLICENSED MSW