Provider Demographics
NPI:1679340335
Name:TROUT, MELLISA RAE
Entity Type:Individual
Prefix:MRS
First Name:MELLISA
Middle Name:RAE
Last Name:TROUT
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 1:945 BARLOW ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4250
Mailing Address - Country:US
Mailing Address - Phone:231-268-0007
Mailing Address - Fax:231-525-3170
Practice Address - Street 1:975 S MORRISON RD
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9078
Practice Address - Country:US
Practice Address - Phone:989-387-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician