Provider Demographics
NPI:1700015302
Name:BRUNDAGE, MELISSA B (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:B
Last Name:BRUNDAGE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1202
Mailing Address - Country:US
Mailing Address - Phone:614-481-3224
Mailing Address - Fax:614-481-3224
Practice Address - Street 1:1660 NW PROFESSIONAL PLZ
Practice Address - Street 2:SUITE F
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3854
Practice Address - Country:US
Practice Address - Phone:614-263-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health