Provider Demographics
NPI:1578212080
Name:MCCALLUM, MELANIE (MS)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:GRETZINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3502 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4454
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:
Practice Address - Street 1:2524 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5269
Practice Address - Country:US
Practice Address - Phone:601-634-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional