Provider Demographics
NPI:1063773505
Name:PETESCH, MELISSA R (LMSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:PETESCH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10050 NW HWY 24 #7
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:KS
Mailing Address - Zip Code:66539
Mailing Address - Country:US
Mailing Address - Phone:785-447-0431
Mailing Address - Fax:
Practice Address - Street 1:210 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:KS
Practice Address - Zip Code:66901-5200
Practice Address - Country:US
Practice Address - Phone:785-243-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
KS8648104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker