Healthcare Provider Details

I. General information

NPI: 1285963496
Provider Name (Legal Business Name): MELISSA CAROLINE SCANLAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 ARIEL ST N
MAPLEWOOD MN
55109-2248
US

IV. Provider business mailing address

2345 ARIEL ST N
MAPLEWOOD MN
55109-2248
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-4793
  • Fax: 651-254-0877
Mailing address:
  • Phone: 651-254-4793
  • Fax: 651-254-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17540
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: