Healthcare Provider Details

I. General information

NPI: 1427263979
Provider Name (Legal Business Name): MELANIE A MARTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NORTH FIRST ST.
STEELVILLE MO
65565
US

IV. Provider business mailing address

PO BOX 1267
CAPE GIRARDEAU MO
63702-1267
US

V. Phone/Fax

Practice location:
  • Phone: 573-775-4445
  • Fax: 573-775-4467
Mailing address:
  • Phone: 573-332-0416
  • Fax: 573-335-2698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2005016774
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: