Provider Demographics
NPI:1457880825
Name:CARLSON, MELLISA ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELLISA
Middle Name:ANN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MELLISA
Other - Middle Name:ANN
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:6795 N MINERAL DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8700
Practice Address - Country:US
Practice Address - Phone:208-769-4222
Practice Address - Fax:844-803-7399
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-36548104100000X
IDLCSW-391211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker