Healthcare Provider Details

I. General information

NPI: 1417365065
Provider Name (Legal Business Name): MELINDA GAIL HIMSTEDT LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELINDA GAIL DAVIS

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 KANAWHA BLVD E
CHARLESTON WV
25311-2413
US

IV. Provider business mailing address

PO BOX 9569
SOUTH CHARLESTON WV
25309-0569
US

V. Phone/Fax

Practice location:
  • Phone: 681-265-9047
  • Fax: 681-265-9210
Mailing address:
  • Phone: 681-265-9047
  • Fax: 681-265-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCP00944410
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00944410
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: