Healthcare Provider Details

I. General information

NPI: 1821499609
Provider Name (Legal Business Name): MELISSA SOUTH L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 BOWDEN ST
SALUDA VA
23149
US

IV. Provider business mailing address

PO BOX 40
SALUDA VA
23149-0040
US

V. Phone/Fax

Practice location:
  • Phone: 804-758-4035
  • Fax: 804-695-8122
Mailing address:
  • Phone: 804-758-4035
  • Fax: 804-695-8122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008712
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: