Healthcare Provider Details

I. General information

NPI: 1093149452
Provider Name (Legal Business Name): MELISSA BUCKLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 06/05/2023
Certification Date: 06/04/2023
Deactivation Date: 11/09/2022
Reactivation Date: 12/20/2022

III. Provider practice location address

325 IL ROUTE 2
DIXON IL
61021-9118
US

IV. Provider business mailing address

311 W PARK ST
MORRISON IL
61270-2319
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6611
  • Fax:
Mailing address:
  • Phone: 815-213-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149.024911
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149.024911
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: