Provider Demographics
NPI:1659631414
Name:PEDERSEN, MELISSA ANN
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:PEDERSEN
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 1:13460 WALSH DR
Mailing Address - Street 2:
Mailing Address - City:BOYS TOWN
Mailing Address - State:NE
Mailing Address - Zip Code:68010-7529
Mailing Address - Country:US
Mailing Address - Phone:402-498-3358
Mailing Address - Fax:402-498-3375
Practice Address - Street 1:13460 WALSH DR
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010-7529
Practice Address - Country:US
Practice Address - Phone:402-498-3358
Practice Address - Fax:402-498-3375
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4651101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026139700Medicaid
NE47037660631Medicaid
NE10025745300Medicaid