Provider Demographics
NPI:1366181927
Name:HARRISON, MELISSA (APSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 CARSTENSEN LN APT A
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4262
Mailing Address - Country:US
Mailing Address - Phone:715-902-9965
Mailing Address - Fax:
Practice Address - Street 1:2733 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5545
Practice Address - Country:US
Practice Address - Phone:920-497-6200
Practice Address - Fax:920-497-3135
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000000000000Medicaid