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NPI Code Detail

MEDICARE: MELISSA A DETRIE LPC, SAC-IT

MEDICARE: MELISSA A DETRIE LPC, SAC-IT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor6401225600MI
2101YP2500XProfessional Counselor11880-125WI
3101YA0400XAddiction (Substance Use Disorder) Counselor20395-130WI

General Provider Information

NPI Number : 1205525904
Entity Type Code : Individual
Provider Name (Legal Business Name) : MELISSA A DETRIE LPC, SAC-IT
Provider Business Mailing Address
First Line : 1566 W MASON ST STE 5
Second Line :
City : GREEN BAY
State : WI
Zip : 54303-2274
Country : US
Telephone Number : 920-212-1612
Fax Number :
Provider Business Practice Location Address
First Line : 2640 W POINT RD
Second Line :
City : GREEN BAY
State : WI
Zip : 54304-1344
Country : US
Telephone Number : 920-490-3875
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/08/2023
Last Update Date : 04/17/2026

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