Healthcare Provider Details

I. General information

NPI: 1144134081
Provider Name (Legal Business Name): MELANIE DANIELA BOURGOINE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE RUIZ

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 MAIN ST
OSWEGO IL
60543-9893
US

IV. Provider business mailing address

2629 N 3659TH RD
SHERIDAN IL
60551-9595
US

V. Phone/Fax

Practice location:
  • Phone: 630-519-1010
  • Fax: 630-405-7209
Mailing address:
  • Phone: 630-429-6907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.108462
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: