Provider Demographics
NPI:1992381891
Name:SUNNARBORG, MELISSA JENNIFER
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JENNIFER
Last Name:SUNNARBORG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8663
Mailing Address - Country:US
Mailing Address - Phone:320-253-3540
Mailing Address - Fax:
Practice Address - Street 1:538 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8663
Practice Address - Country:US
Practice Address - Phone:320-253-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3889106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN188731327Medicaid