Provider Demographics
NPI:1184984239
Name:PHELPS, MELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:10401 LINN STATION RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3842
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:502-589-8745
Practice Address - Street 1:600 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1716
Practice Address - Country:US
Practice Address - Phone:502-583-3951
Practice Address - Fax:502-581-9234
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
KY2552661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1184984239Medicaid