Provider Demographics
NPI:1467126219
Name:CARROLL, MELISSA (MSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:869 20TH ST
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MI
Mailing Address - Zip Code:49078-9739
Mailing Address - Country:US
Mailing Address - Phone:269-204-8982
Mailing Address - Fax:
Practice Address - Street 1:445 W MICHIGAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3750
Practice Address - Country:US
Practice Address - Phone:269-488-5462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851098462104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker