Healthcare Provider Details

I. General information

NPI: 1225438476
Provider Name (Legal Business Name): MELISSANNE GHISELLI ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISSY ANASTASIA GALLO

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E KEN PRATT BLVD
LONGMONT CO
80504-5311
US

IV. Provider business mailing address

1750 E KEN PRATT BLVD
LONGMONT CO
80504-5311
US

V. Phone/Fax

Practice location:
  • Phone: 720-718-7000
  • Fax: 720-718-0900
Mailing address:
  • Phone: 720-718-7000
  • Fax: 720-718-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW27574
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09926021
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: