Healthcare Provider Details

I. General information

NPI: 1013580851
Provider Name (Legal Business Name): RAELYN MELTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 RED BUD LN
VIENNA IL
62995-1792
US

IV. Provider business mailing address

101 OLIVER ST
VIENNA IL
62995-1660
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-3079
  • Fax: 618-658-2759
Mailing address:
  • Phone: 618-658-2611
  • Fax: 618-658-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: