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General NPI Number Information
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NPI Number | 1629746664
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Entity Type | Organization
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Legal Business Name | MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES
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Dates
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Enumeration Date | 09/03/2021
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Last Update Date | 11/08/2021
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Provider Practice Location Address
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Address Line | 40315 MICHIGAN AVE # 1081
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City | CANTON
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State | MI
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Zip | 48188-2908
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Country | US
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Telephone | 734-431-8503
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Fax |
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Provider Business Mailing Address
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Address Line | 9517 LAKESIDE DR
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City | YPSILANTI
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State | MI
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Zip | 48197-3033
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NERISSA A LEGG
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Credential | LPC
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Telephone | 734-431-8503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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