Provider Demographics
NPI:1639313539
Name:LEVERENCE, MELISSA ANN (LICSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:LEVERENCE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-379-1704
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:2405 8TH ST S STE 200
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4200
Practice Address - Country:US
Practice Address - Phone:218-331-4866
Practice Address - Fax:218-331-4867
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNAP09-524101YM0800X
ND4244101YM0800X
MN196531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health