Healthcare Provider Details

I. General information

NPI: 1689123374
Provider Name (Legal Business Name): MELISSA M. STEPHAN MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA M KING

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 VICTORY NOLL DR
HUNTINGTON IN
46750-0037
US

IV. Provider business mailing address

909 E STATE BLVD
FORT WAYNE IN
46805-3458
US

V. Phone/Fax

Practice location:
  • Phone: 260-335-3730
  • Fax: 260-244-5435
Mailing address:
  • Phone: 260-482-9125
  • Fax: 260-481-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39005992A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: