Provider Demographics
NPI:1790328813
Name:LOCKETT, MELANIE NOEL (LLMSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:NOEL
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3681
Mailing Address - Country:US
Mailing Address - Phone:269-323-1954
Mailing Address - Fax:
Practice Address - Street 1:625 HARRISON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3681
Practice Address - Country:US
Practice Address - Phone:269-323-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851103070104100000X
MI68011030701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20-0034091Medicaid