Provider Demographics
NPI:1538762265
Name:MOOD, MELANI IRENE (TLLP, CAADC)
Entity type:Individual
Prefix:
First Name:MELANI
Middle Name:IRENE
Last Name:MOOD
Suffix:
Gender:F
Credentials:TLLP, CAADC
Other - Prefix:
Other - First Name:MELANI
Other - Middle Name:IRENE
Other - Last Name:BAKER, BAKER-MOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MELANI BAKER-MOOD
Mailing Address - Street 1:1200 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:615-578-6508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6362009521103TA0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)