MEDICARE: MELISSA PATTERSON THERAPY PLLC (BOULEVARD THERAPY)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1144999087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELISSA PATTERSON THERAPY PLLC (BOULEVARD THERAPY)

Provider Business Mailing Address
First Line	:	317 WAYZATA BLVD E
Second Line	:
City	:	WAYZATA
State	:	MN
Zip	:	55391-1683
Country	:	US
Telephone Number	:	612-819-4278
Fax Number	:

Provider Business Practice Location Address
First Line	:	317 WAYZATA BLVD E
Second Line	:
City	:	WAYZATA
State	:	MN
Zip	:	55391-1683
Country	:	US
Telephone Number	:	612-819-4278
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	MELISSA PATTERSON
Credential	:	LPCC, LADC
Telephone Number	:	612-819-4278

Provider Enumeration Date	:	09/13/2021
Last Update Date	:	10/06/2021

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