Provider Demographics
NPI:1568648558
Name:DAVIS, MELISSA COSTIGAN (LCPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:COSTIGAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ROSE
Other - Last Name:COSTIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:511 S 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4225
Mailing Address - Country:US
Mailing Address - Phone:406-599-7612
Mailing Address - Fax:
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:#321
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6241
Practice Address - Country:US
Practice Address - Phone:406-599-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional