Provider Demographics
NPI:1487957866
Name:COWLES, MELISSA MANGENE (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MANGENE
Last Name:COWLES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNNE
Other - Last Name:MANGENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1633 ROCKY GLEN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8669
Mailing Address - Country:US
Mailing Address - Phone:301-466-4043
Mailing Address - Fax:
Practice Address - Street 1:1515 MOCKINGBIRD LN
Practice Address - Street 2:SUITE 1015
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3236
Practice Address - Country:US
Practice Address - Phone:704-525-3255
Practice Address - Fax:704-525-0949
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0051151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8703015Medicaid