Healthcare Provider Details

I. General information

NPI: 1063773505
Provider Name (Legal Business Name): MELISSA R PETESCH LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 5TH ST
CLAY CENTER KS
67432-2502
US

IV. Provider business mailing address

805 5TH ST
CLAY CENTER KS
67432-2502
US

V. Phone/Fax

Practice location:
  • Phone: 785-630-8556
  • Fax:
Mailing address:
  • Phone: 785-630-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8648
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: