Basic Information
| Provider Information | |||||||||
| NPI: | 1588061592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINGSWORTH | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5904 E STATE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468157637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602039185 | ||||||||
| FaxNumber: | 2602039187 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 E STATE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468053404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604812700 | ||||||||
| FaxNumber: | 2604812709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2014 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33007721A | IN | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 34009112A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 34009112A | 01 | IN | INDIANA BEHAVIORAL HEALTH BOARD | OTHER |