Provider Demographics
NPI:1659475341
Name:BIRDWELL, MELISSA JO (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JO
Last Name:BIRDWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:2001 STONEBROOK PL
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-1000
Practice Address - Fax:423-224-1023
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW0000004543104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
178143OtherANTHEM PREF TRIGON
359996OtherMANAGED HEALTH NET
4103787OtherMAGELLAN NAVIGATOR
4103787OtherMAGELLAN SUMMIT
334969OtherVALUE OPTIONS
5631185OtherFIRST HEALTH
178143OtherANTHEM PROF TRIGON
4103787OtherMAGELLAN PINNACLE
TN3920247Medicare ID - Type UnspecifiedGRP
359996OtherMANAGED HEALTH NET