Healthcare Provider Details

I. General information

NPI: 1285220194
Provider Name (Legal Business Name): MELINDA CHRISTINE SHADE BSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W JOHNSTOWN RD
COLUMBUS OH
43230-2731
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 614-729-2024
  • Fax: 614-729-2030
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2005296
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: