Provider Demographics
NPI:1790106722
Name:CRUIKSHANK, MELISSA (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CRUIKSHANK
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BRAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1212 S 70TH ST
Mailing Address - Street 2:SUITE 115-A
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1212 S 70TH ST
Practice Address - Street 2:SUITE 115-A
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3105
Practice Address - Country:US
Practice Address - Phone:414-312-1394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5244-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional