Healthcare Provider Details

I. General information

NPI: 1194733212
Provider Name (Legal Business Name): MELISSA JEAN GROVE M.S., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4054 MCKINNEY AVE SUITE 102
DALLAS TX
75204-8212
US

IV. Provider business mailing address

4054 MCKINNEY AVE SUITE 102
DALLAS TX
75204-8212
US

V. Phone/Fax

Practice location:
  • Phone: 214-520-6308
  • Fax: 214-521-9172
Mailing address:
  • Phone: 214-520-6308
  • Fax: 214-521-9172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15309
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: