Provider Demographics
NPI:1932548583
Name:PEDERSEN, MELINDA M
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:M
Last Name:PEDERSEN
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 1:310 LANCE DR.
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TWIN LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:53181
Mailing Address - Country:US
Mailing Address - Phone:608-400-4320
Mailing Address - Fax:
Practice Address - Street 1:310 LANCE DR.
Practice Address - Street 2:SUITE 210
Practice Address - City:TWIN LAKES
Practice Address - State:WI
Practice Address - Zip Code:53181
Practice Address - Country:US
Practice Address - Phone:608-295-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6523-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional