Provider Demographics
NPI:1689123374
Name:STEPHAN, MELISSA M (MS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3458
Mailing Address - Country:US
Mailing Address - Phone:260-482-9125
Mailing Address - Fax:260-481-2838
Practice Address - Street 1:788 W CONNEXION WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1046
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health