Provider Demographics
NPI:1609476738
Name:MELROE, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MELROE
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 1:1120 TOWN CENTRE DR APT 12
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2321
Mailing Address - Country:US
Mailing Address - Phone:612-518-5682
Mailing Address - Fax:
Practice Address - Street 1:700 TWELVE OAKS CENTER DR STE 700
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4405
Practice Address - Country:US
Practice Address - Phone:612-518-5682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3859106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist