Provider Demographics
NPI:1972129336
Name:DIERICKX, MELANIE (LMSW)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:DIERICKX
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E GEORGE WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-1230
Mailing Address - Country:US
Mailing Address - Phone:563-676-2357
Mailing Address - Fax:
Practice Address - Street 1:218 1/2 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ELDRIDGE
Practice Address - State:IA
Practice Address - Zip Code:52748-1208
Practice Address - Country:US
Practice Address - Phone:563-676-2357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099976104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA099976OtherBOARD OF SOCIAL WORK LICENSE