Basic Information
| Provider Information | |||||||||
| NPI: | 1659335180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUPLE | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 812 E JOLLY RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489106818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468410 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 E JOLLY RD | ||||||||
| Address2: | SUITE G14 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489106818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468276 | ||||||||
| FaxNumber: | 5173468290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801061986 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.