Provider Demographics
NPI:1851585418
Name:GREGORY, MELISSA L (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:L
Last Name:GREGORY
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E PIER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1939
Mailing Address - Country:US
Mailing Address - Phone:262-284-5789
Mailing Address - Fax:
Practice Address - Street 1:101 E PIER ST STE 2
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1939
Practice Address - Country:US
Practice Address - Phone:262-284-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3373-57103TC0700X
VA08100004023103T00000X
WI3373103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI903417100Medicaid
MN903417100Medicaid