Provider Demographics
NPI:1467515932
Name:THAYNE, MELISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:THAYNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:MT
Mailing Address - Zip Code:59829-0581
Mailing Address - Country:US
Mailing Address - Phone:801-427-2607
Mailing Address - Fax:801-756-3698
Practice Address - Street 1:274 OLD CORVALLIS RD UNIT Y
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-3213
Practice Address - Country:US
Practice Address - Phone:801-756-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3496723501104100000X
MT39783104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker