Healthcare Provider Details

I. General information

NPI: 1053424770
Provider Name (Legal Business Name): MELISSA L. BLACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA L WASHAM

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 PASEO VERDE PKWY STE 190
HENDERSON NV
89052-2703
US

IV. Provider business mailing address

2200 PASEO VERDE PKWY STE 190
HENDERSON NV
89052-2703
US

V. Phone/Fax

Practice location:
  • Phone: 573-330-9919
  • Fax:
Mailing address:
  • Phone: 573-330-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005000353
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: