Healthcare Provider Details

I. General information

NPI: 1184638587
Provider Name (Legal Business Name): MELINDA J SIMON PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5123 W ST JOE HWY SUITE 103
LANSING MI
48917-4093
US

IV. Provider business mailing address

5123 W ST JOE HWY SUITE 103
LANSING MI
48917-4093
US

V. Phone/Fax

Practice location:
  • Phone: 517-323-4099
  • Fax: 513-323-3334
Mailing address:
  • Phone: 517-323-4099
  • Fax: 513-323-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301009976
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: