1568685121 NPI number — MANDI JO MELTON LCSW

Table of content: MANDI JO MELTON LCSW (NPI 1568685121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568685121 NPI number — MANDI JO MELTON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELTON
Provider First Name:
MANDI
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAPER
Provider Other First Name:
MANDI
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568685121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
137 TIMBERLAND RIDGE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70507-2743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-280-0539
Provider Business Mailing Address Fax Number:
337-785-1188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 E PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWLEY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70526-2468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-280-0539
Provider Business Practice Location Address Fax Number:
337-785-1188
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7242 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1549185 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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