Provider Demographics
NPI:1285900084
Name:WILSON, MELISSA DIANE (MA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 KALE PL APT 3
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-9168
Mailing Address - Country:US
Mailing Address - Phone:808-651-4183
Mailing Address - Fax:
Practice Address - Street 1:4441 KALE PL APT 3
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766
Practice Address - Country:US
Practice Address - Phone:808-651-4183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT-559106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist