Provider Demographics
NPI:1417246364
Name:MOE, MELISSA SUE (BSW, MSW)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:SUE
Last Name:MOE
Suffix:
Gender:F
Credentials:BSW, MSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:SUE
Other - Last Name:HITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:789 N CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-8250
Mailing Address - Country:US
Mailing Address - Phone:989-539-2141
Mailing Address - Fax:989-539-2143
Practice Address - Street 1:3611 NORTH SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-631-2320
Practice Address - Fax:989-631-9903
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010915401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1881622892Medicaid