Healthcare Provider Details

I. General information

NPI: 1457570764
Provider Name (Legal Business Name): MELISSA MEBOE MSSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 W ROCKWELL ST
JEFFERSON WI
53549-2048
US

IV. Provider business mailing address

147 W ROCKWELL ST
JEFFERSON WI
53549-2048
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-6255
  • Fax:
Mailing address:
  • Phone: 920-674-6255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number88723-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: