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General NPI Number Information
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NPI Number | 1902974231
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Entity Type | Organization
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Legal Business Name | KRISTIN M MELOTIK PLC
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 10/13/2009
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Provider Practice Location Address
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Address Line | 120 WEST MAIN ST STE 202
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City | NORTHVILLE
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State | MI
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Zip | 48167
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Country | US
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Telephone | 248-347-6110
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Fax | 248-347-1120
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Provider Business Mailing Address
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Address Line | 120 WEST MAIN ST STE 202
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City | NORTHVILLE
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State | MI
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Zip | 48167
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Country | US
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Telephone | 248-347-6110
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Fax | 248-347-1120
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Authorized Official
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Title or Position | AGENT PSYCHOTHERAPIST
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Name | MRS. KRISTIN MARIE PERIARD
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Credential | MSW LMSW
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Telephone | 248-347-6110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801067292
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License Number State | MI
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