Basic Information
| Provider Information | |||||||||
| NPI: | 1558640862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISP | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1212 BATH AVE STE 595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064654152 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1212 BATH AVE STE 595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064654152 | ||||||||
| FaxNumber: | 9136215730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S 1000162 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 5663 | KY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 254125 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.