Provider Demographics
NPI:1568685121
Name:MELTON, MANDI JO (LCSW)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:JO
Last Name:MELTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:JO
Other - Last Name:LAPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:137 TIMBERLAND RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2743
Mailing Address - Country:US
Mailing Address - Phone:337-280-0539
Mailing Address - Fax:337-785-1188
Practice Address - Street 1:318 E PARK ST
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2468
Practice Address - Country:US
Practice Address - Phone:337-280-0539
Practice Address - Fax:337-785-1188
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA72421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1549185Medicaid
LA5DG83Medicare PIN
LA1549185Medicaid
LA5DG12Medicare PIN
LA4H359CG12Medicare PIN