Provider Demographics
NPI:1255411823
Name:PETERSON, MELISSA EVE (LMSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:EVE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 CENTERLINE RD
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:MI
Mailing Address - Zip Code:48881-9426
Mailing Address - Country:US
Mailing Address - Phone:616-897-1277
Mailing Address - Fax:
Practice Address - Street 1:375 APPLE TREE DR
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-7506
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:616-527-0538
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802066484104100000X
MI68010934721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid