Provider Demographics
NPI:1710200951
Name:PFENNING, MELISSA DIANE (MED, LCPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:PFENNING
Suffix:
Gender:F
Credentials:MED, LCPC
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 3620
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-0018
Mailing Address - Country:US
Mailing Address - Phone:208-699-0679
Mailing Address - Fax:
Practice Address - Street 1:1616 E SELTICE WAY STE 213
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83835-0000
Practice Address - Country:US
Practice Address - Phone:208-699-0679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 4662101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCPC 4662OtherSTATE OF IDAHO LICENSING BOARD