Provider Demographics
NPI:1265003024
Name:LONGTINE, MELISSA (LPCC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LONGTINE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16055 BLACKHAWK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56554-9318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 16TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4055
Practice Address - Country:US
Practice Address - Phone:701-809-5370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND538-9-15-05-341101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional