Basic Information
| Provider Information | |||||||||
| NPI: | 1184638587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5123 W ST JOE HWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489174093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173234099 | ||||||||
| FaxNumber: | 5133233334 | ||||||||
| Practice Location | |||||||||
| Address1: | 5123 W ST JOE HWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489174093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173234099 | ||||||||
| FaxNumber: | 5133233334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 01/09/2013 | ||||||||
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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 | 103T00000X | 6301009976 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 680B345180 | 01 | MI | BCBS | OTHER |