Provider Demographics
NPI:1386997096
Name:ROLEY, MELISSA LYNNE (MS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNNE
Last Name:ROLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MISA
Other - Middle Name:LYNNE
Other - Last Name:ROLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 5121
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33737-5121
Mailing Address - Country:US
Mailing Address - Phone:912-323-7694
Mailing Address - Fax:
Practice Address - Street 1:5121 27TH AVE S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-5413
Practice Address - Country:US
Practice Address - Phone:912-323-7694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003584101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor