Provider Demographics
NPI:1215331509
Name:DANE, MELISSA (MA)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:
Last Name:DANE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 231
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:62848-0231
Mailing Address - Country:US
Mailing Address - Phone:618-533-1391
Mailing Address - Fax:618-533-1200
Practice Address - Street 1:904 E MARTIN LUTHER KING DR.
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:618-533-1200
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370915481007Medicaid