Provider Demographics
NPI:1831513969
Name:DAVID, MELISSA (LICSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DAVID
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 1:2105 MINNEHAHA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3107
Mailing Address - Country:US
Mailing Address - Phone:651-341-0846
Mailing Address - Fax:
Practice Address - Street 1:2105 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3107
Practice Address - Country:US
Practice Address - Phone:651-341-0846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN203951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical