Provider Demographics
NPI:1740004084
Name:DEFOREST, MELISSA JO (MS, LMFT, CEDS-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JO
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:MS, LMFT, CEDS-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 NE STUCKI AVE STE 308
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6951
Mailing Address - Country:US
Mailing Address - Phone:503-862-3476
Mailing Address - Fax:
Practice Address - Street 1:1915 NE STUCKI AVE STE 308
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97006-6951
Practice Address - Country:US
Practice Address - Phone:503-862-3476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT135687106H00000X
WALF61289971106H00000X
ORT1330106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist