Basic Information
| Provider Information | |||||||||
| NPI: | 1265869796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAMIGNA | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNO | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 170 N ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | VENUS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760844852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252323021 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1380 RIVER BEND | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147431272 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 04/13/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 17026 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 25105 | TX | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.