Provider Demographics
NPI:1609207042
Name:KNOX, MELLANIE
Entity Type:Individual
Prefix:
First Name:MELLANIE
Middle Name:
Last Name:KNOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21840 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2523
Mailing Address - Country:US
Mailing Address - Phone:248-298-9215
Mailing Address - Fax:
Practice Address - Street 1:851 WENDOVER BLVD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-5053
Practice Address - Country:US
Practice Address - Phone:248-298-9215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MI64010139411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional