Provider Demographics
NPI:1245639335
Name:IRISARRI, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:IRISARRI
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 1:576 BIELENBERG DR
Mailing Address - Street 2:#250
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1734
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:
Practice Address - Street 1:576 BIELENBERG DR
Practice Address - Street 2:#250
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1734
Practice Address - Country:US
Practice Address - Phone:651-645-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical