Provider Demographics
NPI:1942778360
Name:HEIENICKLE, MELYNDA (BSED, MC, CSC, PLPC)
Entity Type:Individual
Prefix:MRS
First Name:MELYNDA
Middle Name:
Last Name:HEIENICKLE
Suffix:
Gender:F
Credentials:BSED, MC, CSC, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 LA BARON LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6359
Mailing Address - Country:US
Mailing Address - Phone:314-458-5233
Mailing Address - Fax:
Practice Address - Street 1:1480 WOODSTONE DR STE 112
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-6872
Practice Address - Country:US
Practice Address - Phone:636-362-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YS0200X
MO2018036494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool