Healthcare Provider Details

I. General information

NPI: 1215391479
Provider Name (Legal Business Name): BRIDGETTE MELTON PSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 SCHAEFER RD SUITE 2
DEARBORN MI
48126-1974
US

IV. Provider business mailing address

6425 SCHAEFER RD SUITE 2
DEARBORN MI
48126-1974
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-2606
  • Fax:
Mailing address:
  • Phone: 313-846-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number6803087001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: