Provider Demographics
NPI:1528272051
Name:FORD, MELISSA A (MS,LPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:FORD
Suffix:
Gender:F
Credentials:MS,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S29W29350 ANCESTRAL DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-9514
Mailing Address - Country:US
Mailing Address - Phone:262-219-5433
Mailing Address - Fax:262-201-4262
Practice Address - Street 1:S29W29350 ANCESTRAL DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-9514
Practice Address - Country:US
Practice Address - Phone:262-219-5433
Practice Address - Fax:262-201-4262
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2829-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43550000Medicaid