Healthcare Provider Details

I. General information

NPI: 1467555029
Provider Name (Legal Business Name): MELANIE JEAN WHITE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 4TH ST S
FARGO ND
58103
US

IV. Provider business mailing address

501 4TH ST S
FARGO ND
58103
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax: 701-281-5786
Mailing address:
  • Phone: 701-476-7200
  • Fax: 701-281-5786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW10933
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW3485
License Number StateND

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: