Provider Demographics
NPI:1679944482
Name:TINERVIA, MELISSA (LLMSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:TINERVIA
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MANTHEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1121 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3062
Mailing Address - Country:US
Mailing Address - Phone:517-914-1924
Mailing Address - Fax:
Practice Address - Street 1:300 W LOUIS GLICK HWY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1228
Practice Address - Country:US
Practice Address - Phone:517-782-9905
Practice Address - Fax:517-796-7022
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098502101YA0400X, 101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical