Basic Information
| Provider Information | |||||||||
| NPI: | 1487957866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COWLES | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MANGENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANGENE | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1633 ROCKY GLEN LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282148669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014664043 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1515 MOCKINGBIRD LN | ||||||||
| Address2: | SUITE 1015 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045253255 | ||||||||
| FaxNumber: | 7045250949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 12/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C005115 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8703015 | 05 | NC | MEDICAID |