Provider Demographics
NPI:1649627019
Name:CHISMODY, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:CHISMODY
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 1:3314 HEALY ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-4751
Mailing Address - Country:US
Mailing Address - Phone:248-310-9792
Mailing Address - Fax:
Practice Address - Street 1:3314 HEALY ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-4751
Practice Address - Country:US
Practice Address - Phone:248-310-9792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010704761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical