Provider Demographics
NPI:1629746664
Name:MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES
Entity Type:Organization
Organization Name:MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NERISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEGG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:734-431-8503
Mailing Address - Street 1:9517 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40315 MICHIGAN AVE # 1081
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2908
Practice Address - Country:US
Practice Address - Phone:734-431-8503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty