Provider Demographics
NPI:1144066762
Name:GEURTSEN, MELISSA NICHOLE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICHOLE
Last Name:GEURTSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N67W25376 BRECKENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-1262
Mailing Address - Country:US
Mailing Address - Phone:262-623-2049
Mailing Address - Fax:
Practice Address - Street 1:N67W25376 BRECKENRIDGE CT
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-1262
Practice Address - Country:US
Practice Address - Phone:262-623-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10948-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional