Provider Demographics
NPI:1336535640
Name:SUNDWALL, MELISSA (LPC RASACII)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SUNDWALL
Suffix:
Gender:F
Credentials:LPC RASACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 S CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3003
Mailing Address - Country:US
Mailing Address - Phone:417-496-3907
Mailing Address - Fax:
Practice Address - Street 1:2335 S CLAY AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3003
Practice Address - Country:US
Practice Address - Phone:417-496-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012013276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional