Healthcare Provider Details

I. General information

NPI: 1366771644
Provider Name (Legal Business Name): MELANIE RENEE ROSERIE LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 MISSILE AVENUE MINOT AFB - 5 MDG MENTAL HEALTH CLINIC
MINOT ND
58705
US

IV. Provider business mailing address

194 MISSILE AVENUE
MINOT AFB ND
58704
US

V. Phone/Fax

Practice location:
  • Phone: 701-723-5527
  • Fax:
Mailing address:
  • Phone: 701-723-5527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16695
License Number StateMD

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: