Provider Demographics
NPI:1679072839
Name:LAIRD, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LAIRD
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 1:4039 MARIE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9035
Mailing Address - Country:US
Mailing Address - Phone:517-745-6751
Mailing Address - Fax:
Practice Address - Street 1:1206 CLINTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2005
Practice Address - Country:US
Practice Address - Phone:517-783-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011021841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical