Basic Information
| Provider Information | |||||||||
| NPI: | 1215331509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 231 | ||||||||
| Address2: | |||||||||
| City: | IRVINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628480231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185331200 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 E MARTIN LUTHER KING DR. | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185331200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2014 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 370915481007 | 05 | IL | MEDICAID |