Provider Demographics
NPI:1649724105
Name:MELLGREN-SIDMORE, MELANIE (LAC 4184)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MELLGREN-SIDMORE
Suffix:
Gender:F
Credentials:LAC 4184
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 1ST AVE E STE 214
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4978
Mailing Address - Country:US
Mailing Address - Phone:406-261-5005
Mailing Address - Fax:
Practice Address - Street 1:307 1ST AVE E STE 214
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4978
Practice Address - Country:US
Practice Address - Phone:406-261-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLAC 4184101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)