Provider Demographics
NPI:1306429139
Name:GREEN, MELISSA LASHELL (MSW, CMHT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LASHELL
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSW, CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3087 SIMPSON HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3077
Mailing Address - Country:US
Mailing Address - Phone:601-847-4410
Mailing Address - Fax:601-847-7634
Practice Address - Street 1:3087 SIMPSON HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3077
Practice Address - Country:US
Practice Address - Phone:601-847-4410
Practice Address - Fax:601-847-7634
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health