Healthcare Provider Details

I. General information

NPI: 1558640862
Provider Name (Legal Business Name): MELINDA CRISP LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 23RD ST STE 8B
ASHLAND KY
41101-2845
US

IV. Provider business mailing address

617 23RD ST STE 8B
ASHLAND KY
41101-2845
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-1290
  • Fax:
Mailing address:
  • Phone: 606-408-1290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS 1000162
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5663
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number254125
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: