Provider Demographics
NPI:1437599149
Name:WICKES, MELISSA D (MA, LCPC)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:D
Last Name:WICKES
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LEBANON AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-2491
Mailing Address - Country:US
Mailing Address - Phone:618-444-1331
Mailing Address - Fax:618-234-7003
Practice Address - Street 1:1600 LEBANON AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-2491
Practice Address - Country:US
Practice Address - Phone:618-444-1331
Practice Address - Fax:618-234-7003
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005608101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional