Provider Demographics
NPI:1295410892
Name:MERIDETH, MELISSA DIANA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DIANA
Last Name:MERIDETH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 AUTUMN DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5152
Mailing Address - Country:US
Mailing Address - Phone:573-620-1935
Mailing Address - Fax:
Practice Address - Street 1:139 AUTUMN DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5152
Practice Address - Country:US
Practice Address - Phone:573-620-1935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120017431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical