Healthcare Provider Details

I. General information

NPI: 1457693962
Provider Name (Legal Business Name): MELISSA FAYE MORAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22625 E MARTIN LAKE DR NE
STACY MN
55079-9376
US

IV. Provider business mailing address

22625 E MARTIN LAKE DR NE
STACY MN
55079-9376
US

V. Phone/Fax

Practice location:
  • Phone: 651-462-0647
  • Fax:
Mailing address:
  • Phone: 651-462-0647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18211
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: