Provider Demographics
NPI:1790337178
Name:WHEELER, MELISSA LYNETTE (SAC-IT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNETTE
Last Name:WHEELER
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4650 LAIRD RD
Mailing Address - Street 2:
Mailing Address - City:SHIOCTON
Mailing Address - State:WI
Mailing Address - Zip Code:54170-8939
Mailing Address - Country:US
Mailing Address - Phone:920-707-0304
Mailing Address - Fax:
Practice Address - Street 1:3301 N BALLARD RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8928
Practice Address - Country:US
Practice Address - Phone:920-733-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18650-130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor