Healthcare Provider Details

I. General information

NPI: 1770080079
Provider Name (Legal Business Name): MELANIE ANN BALLEIN LICDC, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE ANN EVANS

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 MERCY BLVD
MOUNT ORAB OH
45154-0296
US

IV. Provider business mailing address

6480 WELCOME RD
HILLSBORO OH
45133-6992
US

V. Phone/Fax

Practice location:
  • Phone: 937-393-9720
  • Fax:
Mailing address:
  • Phone: 937-763-5411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2005190
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162486
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: