MEDICARE: MELISSA LONGTINE LPCC

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	101YP2500X	Professional Counselor	538-9-15-05-341	ND
2	101YP2500X	Professional Counselor	CC05013	MN

General Provider Information

NPI Number	:	1265003024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA LONGTINE LPCC

Provider Business Mailing Address
First Line	:	16055 BLACKHAWK RD
Second Line	:
City	:	LAKE PARK
State	:	MN
Zip	:	56554-9318
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	808 WASHINGTON AVE STE 22D
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3068
Country	:	US
Telephone Number	:	218-849-7524
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2021
Last Update Date	:	06/19/2025

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