Basic Information
| Provider Information | |||||||||
| NPI: | 1174829865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMINN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 OLD MARS HILL HWY | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287878602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286453687 | ||||||||
| FaxNumber: | 2848484638 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 OLD MARS HILL HWY | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286453687 | ||||||||
| FaxNumber: | 2848484638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2011 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-24097 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 004040655 | 05 | CT | MEDICAID |