Provider Demographics
NPI:1033567706
Name:MADRID, MELISSA ANN (MSW, BHT)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:ANN
Last Name:MADRID
Suffix:
Gender:F
Credentials:MSW, BHT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-1000
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AZ222561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker