Provider Demographics
NPI:1427749605
Name:LEE, MELISSA SHAVON (LLMSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SHAVON
Last Name:LEE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 E MICHIGAN AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3944
Mailing Address - Country:US
Mailing Address - Phone:269-447-3047
Mailing Address - Fax:
Practice Address - Street 1:5725 VENTURE PARK DR STE B
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2816
Practice Address - Country:US
Practice Address - Phone:269-459-8889
Practice Address - Fax:269-620-5985
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511105411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical