Healthcare Provider Details

I. General information

NPI: 1871946749
Provider Name (Legal Business Name): MELISSA BOX LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E LINCOLN ST STE 303
NORMAL IL
61761-6406
US

IV. Provider business mailing address

705 E LINCOLN ST STE 303
NORMAL IL
61761-6406
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-9495
  • Fax:
Mailing address:
  • Phone: 309-451-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.016634
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: