Basic Information
| Provider Information | |||||||||
| NPI: | 1932425550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172584042 | ||||||||
| FaxNumber: | 2172584053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 149008142 | IL | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 149-008142 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.