Provider Demographics
NPI:1932501210
Name:WALLS, MELISSA CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAROL
Last Name:WALLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BEASLEY ST
Mailing Address - Street 2:STE. 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4266
Mailing Address - Country:US
Mailing Address - Phone:859-245-1035
Mailing Address - Fax:
Practice Address - Street 1:900 BEASLEY ST
Practice Address - Street 2:STE. 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4266
Practice Address - Country:US
Practice Address - Phone:859-245-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100363400Medicaid