Provider Demographics
NPI:1215667837
Name:WILLISON, MELINDA
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:WILLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 ROLLING ACRES RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-5330
Mailing Address - Country:US
Mailing Address - Phone:704-315-4333
Mailing Address - Fax:
Practice Address - Street 1:2922 AUDREY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7268
Practice Address - Country:US
Practice Address - Phone:704-709-1147
Practice Address - Fax:980-495-8940
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health