=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811585771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MELISSA CHILD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2021
-----------------------------------------------------
Last Update Date | 12/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3765 US-20
-----------------------------------------------------
City | ISLAND PARK
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-549-9970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2184 CHANNING WAY # 248
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-8034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-279-7924
-----------------------------------------------------
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 | LMSW-40310
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------