Healthcare Provider Details

I. General information

NPI: 1639899842
Provider Name (Legal Business Name): MELINDA KITCHENS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11910 GREENVILLE AVE STE 511
DALLAS TX
75243-9388
US

IV. Provider business mailing address

11910 GREENVILLE AVE STE 511
DALLAS TX
75243-9388
US

V. Phone/Fax

Practice location:
  • Phone: 214-937-9180
  • Fax:
Mailing address:
  • Phone: 214-937-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number67829
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number67829
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: