Basic Information
| Provider Information | |||||||||
| NPI: | 1851725766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LYNCH | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 645 S ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
| FaxNumber: | 8123372438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1092 W COMMUNITY WAY | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471707768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003445502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39002912A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.