Healthcare Provider Details

I. General information

NPI: 1275083685
Provider Name (Legal Business Name): MELISSA SHIGEMATSU LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA ANN FARR

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3481 UNIVERSITY DR S STE 104
FARGO ND
58104-6235
US

IV. Provider business mailing address

3481 UNIVERSITY DR S STE 104
FARGO ND
58104-6235
US

V. Phone/Fax

Practice location:
  • Phone: 701-353-9238
  • Fax: 701-205-1221
Mailing address:
  • Phone: 701-353-9238
  • Fax: 701-205-1221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: