Healthcare Provider Details

I. General information

NPI: 1609291566
Provider Name (Legal Business Name): MELESSA CUNNINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STACKPOLE DR
MACHIAS ME
04654-7000
US

IV. Provider business mailing address

1 STACKPOLE DR
MACHIAS ME
04654-7000
US

V. Phone/Fax

Practice location:
  • Phone: 207-255-0996
  • Fax: 207-255-8748
Mailing address:
  • Phone: 207-255-0996
  • Fax: 207-255-8748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1609291566
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: