Provider Demographics
NPI:1407029606
Name:MCCREADY, MELISSA JO (LPE-I)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JO
Last Name:MCCREADY
Suffix:
Gender:F
Credentials:LPE-I
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JO
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPE-I
Mailing Address - Street 1:829 HALBERT ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2607
Mailing Address - Country:US
Mailing Address - Phone:501-332-4400
Mailing Address - Fax:
Practice Address - Street 1:829 HALBERT ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2607
Practice Address - Country:US
Practice Address - Phone:501-332-4400
Practice Address - Fax:870-246-4184
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06-11EI103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227955719Medicaid