Provider Demographics
NPI:1356662910
Name:CALISTA E. MELKERSMAN
Entity Type:Organization
Organization Name:CALISTA E. MELKERSMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CALISTA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MELKERSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-440-1352
Mailing Address - Street 1:4635 FRANKFORT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-5832
Mailing Address - Country:US
Mailing Address - Phone:314-440-1352
Mailing Address - Fax:
Practice Address - Street 1:4635 FRANKFORT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-5832
Practice Address - Country:US
Practice Address - Phone:314-440-1352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities