Provider Demographics
NPI:1144482266
Name:DALLAS, MELANIE ANN (LPC)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:DALLAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 PINE CREST RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-2662
Mailing Address - Country:US
Mailing Address - Phone:404-808-7740
Mailing Address - Fax:706-692-2091
Practice Address - Street 1:340 PINE CREST RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-2662
Practice Address - Country:US
Practice Address - Phone:404-808-7740
Practice Address - Fax:706-692-2091
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003408101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional