Provider Demographics
NPI:1144956731
Name:BISHOP, MELISSA DIANA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANA
Last Name:BISHOP
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 1:1330 COUNTY ROAD 61
Mailing Address - Street 2:
Mailing Address - City:BILLINGSLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36006
Mailing Address - Country:US
Mailing Address - Phone:334-531-0795
Mailing Address - Fax:
Practice Address - Street 1:2348 COUNTY ROAD 61
Practice Address - Street 2:
Practice Address - City:DEATSVILLE
Practice Address - State:AL
Practice Address - Zip Code:36022-3227
Practice Address - Country:US
Practice Address - Phone:334-531-0795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC3952A101YP2500X
ALLPC05257101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL001002225Medicaid