Provider Demographics
NPI:1619905577
Name:MARQUART-CARLSON, MELISSA S (PHD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:S
Last Name:MARQUART-CARLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:S
Other - Last Name:MARQUART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1501 CREEKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 CREEKSIDE LN
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7351
Practice Address - Country:US
Practice Address - Phone:920-288-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2560103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39149700Medicaid
WIP00460245OtherRAILROAD
WIQ56705Medicare UPIN
WI39149700Medicaid