Provider Demographics
NPI:1396299392
Name:DIDERIKSEN, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:DIDERIKSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N MICHIGAN AVE STE 1430
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7653
Mailing Address - Country:US
Mailing Address - Phone:312-766-6780
Mailing Address - Fax:312-261-5080
Practice Address - Street 1:576 LANKAMP ST NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-1941
Practice Address - Country:US
Practice Address - Phone:269-808-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC013164OtherGA STATE LICENSE
MI6401014452OtherMI STATE LICENSE