Healthcare Provider Details

I. General information

NPI: 1639313539
Provider Name (Legal Business Name): MELISSA ANN LEVERENCE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 218-331-4866
  • Fax: 218-331-4867
Mailing address:
  • Phone: 651-379-1704
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAP09-524
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4244
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19653
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: