Provider Demographics
NPI:1770652273
Name:PEDERSON, MELISSA WHEELOCK (PHD, LP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:WHEELOCK
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 314N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:651-647-5135
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 314N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-645-5323
Practice Address - Fax:651-647-5135
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3802103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical