Healthcare Provider Details

I. General information

NPI: 1558502336
Provider Name (Legal Business Name): MELISSA M HERMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 HIGHWAY 49 N
BEULAH ND
58523-6038
US

IV. Provider business mailing address

1312 HIGHWAY 49 N
BEULAH ND
58523-6038
US

V. Phone/Fax

Practice location:
  • Phone: 701-873-4445
  • Fax: 701-873-4199
Mailing address:
  • Phone: 701-873-4445
  • Fax: 701-873-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3244
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1665
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: