Healthcare Provider Details

I. General information

NPI: 1972586535
Provider Name (Legal Business Name): MARY BETH MELLIN MSW LMSW ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MARY BETH KNAPP CSW

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W COLLEGE AVE
MARQUETTE MI
49855
US

IV. Provider business mailing address

580 W COLLEGE AVE
MARQUETTE MI
49855
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3985
  • Fax: 906-225-4562
Mailing address:
  • Phone: 906-225-3985
  • Fax: 906-225-4562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801068523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: