Provider Demographics
NPI:1447940184
Name:SMITH, MELISSA (BSW, MHP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSW, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RED BUD LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-1792
Mailing Address - Country:US
Mailing Address - Phone:618-658-3079
Mailing Address - Fax:
Practice Address - Street 1:300 RED BUD LN
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1792
Practice Address - Country:US
Practice Address - Phone:618-658-3079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health