=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558640862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELINDA CRISP LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2011
-----------------------------------------------------
Last Update Date | 02/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 23RD ST STE 8B
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-408-1290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 23RD ST STE 8B
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-408-1290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S 1000162
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 5663
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 254125
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------