Provider Demographics
NPI:1124332150
Name:PORCH-DONEGHY, MELLANNIE ROSHELLE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:MELLANNIE
Middle Name:ROSHELLE
Last Name:PORCH-DONEGHY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22850 NOTTINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3395
Mailing Address - Country:US
Mailing Address - Phone:248-416-7771
Mailing Address - Fax:
Practice Address - Street 1:17117 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4602
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional