Provider Demographics
NPI:1598478851
Name:FORTH, MELISSA J (JD, MA, LPCC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:FORTH
Suffix:
Gender:F
Credentials:JD, MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 FILLMORE ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1305
Mailing Address - Country:US
Mailing Address - Phone:612-865-5314
Mailing Address - Fax:
Practice Address - Street 1:LYNLAKE BUILDING
Practice Address - Street 2:621 WEST LAKE STREET, SUITE 350
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408
Practice Address - Country:US
Practice Address - Phone:612-865-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health