Provider Demographics
NPI:1255547139
Name:IVEY, MELISSA JEAN (LCPC)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:JEAN
Last Name:IVEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:MITRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:21 MAIN ST.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6359
Mailing Address - Country:US
Mailing Address - Phone:207-941-8727
Mailing Address - Fax:207-992-2784
Practice Address - Street 1:40 MARKET SQUARE
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1742
Practice Address - Country:US
Practice Address - Phone:207-941-8727
Practice Address - Fax:207-992-2784
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2033101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME275820099Medicaid