Basic Information
| Provider Information | |||||||||
| NPI: | 1528539657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MELISSA L DEL ROSARIO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | DEL ROSARIO | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHILD AND FAMILY THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8155574120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 12134724 | 01 | CAQH | OTHER |