Provider Demographics
NPI:1861741647
Name:MAILLOUX, MELANIE LOUISE (MS)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:LOUISE
Last Name:MAILLOUX
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7003 DACOSTA ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2535
Mailing Address - Country:US
Mailing Address - Phone:313-485-0666
Mailing Address - Fax:
Practice Address - Street 1:6020 W MAPLE RD STE 501
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4409
Practice Address - Country:US
Practice Address - Phone:248-470-7967
Practice Address - Fax:248-764-5820
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013962101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional