Provider Demographics
NPI:1013328103
Name:RICHARDSON, MELANIE (LCSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:RICHARDSON
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 1:2184 CHANNING WAY # 157
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8034
Mailing Address - Country:US
Mailing Address - Phone:801-719-7737
Mailing Address - Fax:
Practice Address - Street 1:1188 W SPORTSPLEX DR STE 203
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-6817
Practice Address - Country:US
Practice Address - Phone:801-719-7737
Practice Address - Fax:888-887-9784
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-36133101YM0800X, 1041C0700X
IDLMSW-33744104100000X
UT117243-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker