MEDICARE: MELISSA DIANE PFENNING M.ED., LCPC

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	LCPC 4662	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LCPC 4662	OTHER	ID	STATE OF IDAHO LICENSING BOARD

General Provider Information

NPI Number	:	1710200951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA DIANE PFENNING M.ED., LCPC

Provider Business Mailing Address
First Line	:	PO BOX 3620
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83877-0018
Country	:	US
Telephone Number	:	208-699-0679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 E SELTICE WAY STE 213
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83835-0000
Country	:	US
Telephone Number	:	208-699-0679
Fax Number	:

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

Provider Enumeration Date	:	03/02/2010
Last Update Date	:	08/05/2011

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Directions to “ MELISSA DIANE PFENNING M.ED., LCPC” Practice Location

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