Provider Demographics
NPI:1538403167
Name:WILSON, MELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-7303
Mailing Address - Country:US
Mailing Address - Phone:812-282-8248
Mailing Address - Fax:812-282-3291
Practice Address - Street 1:2420 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-7303
Practice Address - Country:US
Practice Address - Phone:812-282-8248
Practice Address - Fax:812-282-3291
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007117A1041C0700X
IN33006360A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200056880AMedicaid