Provider Demographics
NPI:1457714404
Name:LANDRAM, MELISSA J (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:LANDRAM
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 1:823 ALLISON AVE
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1760
Mailing Address - Country:US
Mailing Address - Phone:502-827-4699
Mailing Address - Fax:
Practice Address - Street 1:10300 BROOKRIDGE VILLAGE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4474
Practice Address - Country:US
Practice Address - Phone:502-314-2237
Practice Address - Fax:844-379-5157
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7483104100000X
KY2538351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker