Provider Demographics
NPI:1316177629
Name:MAGEE-KAKOURAS, MELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MAGEE-KAKOURAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MAGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2314 CARSON DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-9325
Mailing Address - Country:US
Mailing Address - Phone:704-560-4918
Mailing Address - Fax:704-243-1799
Practice Address - Street 1:216A W. NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6012
Practice Address - Country:US
Practice Address - Phone:704-560-4918
Practice Address - Fax:704-243-1799
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0064511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007330Medicaid
NCC006451OtherLCSW STATE LICENSE