Healthcare Provider Details

I. General information

NPI: 1912142605
Provider Name (Legal Business Name): MELISSA HANEBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SPRING ST
JEFFERSONVILLE IN
47130-3452
US

IV. Provider business mailing address

13415 APPLE TREE LN
PROSPECT KY
40059-9019
US

V. Phone/Fax

Practice location:
  • Phone: 812-280-2080
  • Fax:
Mailing address:
  • Phone: 502-379-5580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: