Basic Information
| Provider Information | |||||||||
| NPI: | 1891414520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | ALLIE | ||||||||
| MiddleName: | MCKENZIE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 533 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628322432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182424075 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628644349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182424075 | ||||||||
| FaxNumber: | 6182424092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2022 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 057.005858 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.