Provider Demographics
NPI:1013286780
Name:MCCUBBIN, MELIA JOY (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MELIA
Middle Name:JOY
Last Name:MCCUBBIN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:MELIA
Other - Middle Name:JOY
Other - Last Name:MCCUBBIN DANIELS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:701 DECATUR AVE N
Mailing Address - Street 2:SUITE 109
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4367
Mailing Address - Country:US
Mailing Address - Phone:763-746-2400
Mailing Address - Fax:
Practice Address - Street 1:701 DECATUR AVE N
Practice Address - Street 2:SUITE 109
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4367
Practice Address - Country:US
Practice Address - Phone:763-746-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN197781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical