Provider Demographics
NPI:1902974231
Name:KRISTIN M MELOTIK PLC
Entity Type:Organization
Organization Name:KRISTIN M MELOTIK PLC
Other - Org Name:KRISTIN MARIE PERIARD MSW, LMSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PERIARD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LMSW
Authorized Official - Phone:248-347-6110
Mailing Address - Street 1:120 WEST MAIN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167
Mailing Address - Country:US
Mailing Address - Phone:248-347-6110
Mailing Address - Fax:248-347-1120
Practice Address - Street 1:120 WEST MAIN ST
Practice Address - Street 2:STE 202
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167
Practice Address - Country:US
Practice Address - Phone:248-347-6110
Practice Address - Fax:248-347-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010672921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P16454Medicare UPIN
MIQ26426190Medicare ID - Type Unspecified