Provider Demographics
NPI:1205308632
Name:GIBBONS, MELISSA RAEN'E (LLMSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:RAEN'E
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:RAEN'E
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14100 NEWBURGH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14100 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5010
Practice Address - Country:US
Practice Address - Phone:734-464-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-25
Last Update Date:2018-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102550104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801102550OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS - MASTER LTD SOCIAL WORKER