Basic Information
| Provider Information | |||||||||
| NPI: | 1497204721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REAVES | ||||||||
| OtherFirstName: | MELISSA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11777 STAMFORD AVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480891261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133122431 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20303 KELLY RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482251206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133081400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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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 | 103T00000X | 6301017085 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.