MEDICARE: MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES

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
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1629746664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES

Provider Business Mailing Address
First Line	:	9517 LAKESIDE DR
Second Line	:
City	:	YPSILANTI
State	:	MI
Zip	:	48197-3033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	40315 MICHIGAN AVE # 1081
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2908
Country	:	US
Telephone Number	:	734-431-8503
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NERISSA A LEGG
Credential	:	LPC
Telephone Number	:	734-431-8503

Provider Enumeration Date	:	09/03/2021
Last Update Date	:	11/08/2021

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