Provider Demographics
NPI:1699062604
Name:WOLLGREN, MELODY (LCSW)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:WOLLGREN
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 1:44 HARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-1610
Mailing Address - Country:US
Mailing Address - Phone:607-742-3829
Mailing Address - Fax:
Practice Address - Street 1:95 ALLENS CREEK RD
Practice Address - Street 2:BLDG 2, STE 325
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-999-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical