Provider Demographics
NPI:1871115337
Name:KING, MELISSA JEAN (PHD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:KING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N MANHATTAN AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-5370
Mailing Address - Country:US
Mailing Address - Phone:525-991-7280
Mailing Address - Fax:
Practice Address - Street 1:205 W 2ND ST STE 437
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1922
Practice Address - Country:US
Practice Address - Phone:218-722-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6535103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling