Provider Demographics
NPI:1467964270
Name:GEORGOPOLIS, MELISSA LEE (LMHC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:GEORGOPOLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LEE
Other - Last Name:GEORGOPOLIS KERLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC
Mailing Address - Street 1:5800 20TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4050
Mailing Address - Country:US
Mailing Address - Phone:727-344-7646
Mailing Address - Fax:
Practice Address - Street 1:5800 20TH AVE S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-4050
Practice Address - Country:US
Practice Address - Phone:727-344-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6910101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022830900Medicaid
FLPENDINGMedicaid