Provider Demographics
NPI:1215344726
Name:MELICK, CHARLES ALVIN III (LCSW - 37691)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALVIN
Last Name:MELICK
Suffix:III
Gender:M
Credentials:LCSW - 37691
Other - Prefix:
Other - First Name:CAM
Other - Middle Name:
Other - Last Name:MELICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1885 GALLUP ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5606
Mailing Address - Country:US
Mailing Address - Phone:801-669-4600
Mailing Address - Fax:
Practice Address - Street 1:2275 W BROADWAY ST
Practice Address - Street 2:STE. G
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:208-524-8004
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-37691101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor