Basic Information
| Provider Information | |||||||||
| NPI: | 1417246364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BSW, MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HITE | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | SUE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 789 N CLARE AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486258250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895392141 | ||||||||
| FaxNumber: | 9895392143 | ||||||||
| Practice Location | |||||||||
| Address1: | 3611 NORTH SAGINAW RD | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896312320 | ||||||||
| FaxNumber: | 9896319903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801091540 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1881622892 | 05 | MI | MEDICAID |