Provider Demographics
NPI:1245856863
Name:BANNEROT, MELISSA ANN CRISP CARPENTER (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN CRISP CARPENTER
Last Name:BANNEROT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BANNEROT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2635 HELMSDALE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7207
Mailing Address - Country:US
Mailing Address - Phone:719-310-6357
Mailing Address - Fax:
Practice Address - Street 1:2514 W COLORADO AVE STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3074
Practice Address - Country:US
Practice Address - Phone:719-310-6357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099267221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty