Provider Demographics
NPI:1720417660
Name:PATRICK, MELISSA ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROSE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:R
Other - Last Name:POPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 W LAKE LANSING RD STE A100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8404
Practice Address - Country:US
Practice Address - Phone:231-620-2750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087717104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker