Healthcare Provider Details

I. General information

NPI: 1215344726
Provider Name (Legal Business Name): CHARLES ALVIN MELICK III LCSW - 37691
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CAM MELICK

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 W BROADWAY ST STE. G
IDAHO FALLS ID
83402-2902
US

IV. Provider business mailing address

1885 GALLUP ST
IDAHO FALLS ID
83404-5606
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax: 208-524-8004
Mailing address:
  • Phone: 801-669-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCSW-37691
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: