Healthcare Provider Details

I. General information

NPI: 1659793149
Provider Name (Legal Business Name): MELISSA CROWELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 W STATE ST
ROCKFORD IL
61101-1214
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-9300
  • Fax:
Mailing address:
  • Phone: 815-387-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149015836
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: