Provider Demographics
NPI:1629195607
Name:MELISSA A STEWART
Entity Type:Organization
Organization Name:MELISSA A STEWART
Other - Org Name:MELISSA'S GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:573-471-4219
Mailing Address - Street 1:106 DACUS DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-9013
Mailing Address - Country:US
Mailing Address - Phone:573-471-4219
Mailing Address - Fax:
Practice Address - Street 1:106 DACUS
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-471-4219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13678892320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853126100Medicaid