Provider Demographics
NPI:1104206655
Name:MELLENTHIN, RUTH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:RUTH
Middle Name:
Last Name:MELLENTHIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 W WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-4412
Mailing Address - Country:US
Mailing Address - Phone:312-810-2601
Mailing Address - Fax:
Practice Address - Street 1:1803 W WILLOW LN
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4412
Practice Address - Country:US
Practice Address - Phone:312-810-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-30
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0186501041C0700X
IL150-013328104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker