Provider Demographics
NPI:1417365065
Name:HIMSTEDT, MELINDA GAIL (LICSW)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:GAIL
Last Name:HIMSTEDT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:GAIL
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9569
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-0569
Mailing Address - Country:US
Mailing Address - Phone:681-265-9047
Mailing Address - Fax:681-265-9210
Practice Address - Street 1:1520 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-2413
Practice Address - Country:US
Practice Address - Phone:681-265-9047
Practice Address - Fax:681-265-9210
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009444101041C0700X
WVCP00944410104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023815000Medicaid
WV9122342Medicare PIN