Healthcare Provider Details

I. General information

NPI: 1053824854
Provider Name (Legal Business Name): THERESA ROSE MELCHING LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA ROSE MELCHING

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

V. Phone/Fax

Practice location:
  • Phone: 616-558-7026
  • Fax:
Mailing address:
  • Phone: 616-456-6571
  • Fax: 616-235-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089779
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: