Healthcare Provider Details

I. General information

NPI: 1467515932
Provider Name (Legal Business Name): MELISSA THAYNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 OLD CORVALLIS RD UNIT Y
HAMILTON MT
59840-3213
US

IV. Provider business mailing address

PO BOX 581
DARBY MT
59829-0581
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-3664
  • Fax:
Mailing address:
  • Phone: 801-427-2607
  • Fax: 801-756-3698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3496723501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number39783
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: