Provider Demographics
NPI:1144232638
Name:NORDSTROM, MELANIE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:JEAN
Last Name:NORDSTROM
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 1:473 W HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-4782
Mailing Address - Country:US
Mailing Address - Phone:618-565-2007
Mailing Address - Fax:618-687-3102
Practice Address - Street 1:473 W HARRISON RD
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-4782
Practice Address - Country:US
Practice Address - Phone:618-565-2007
Practice Address - Fax:618-687-3102
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0100101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03932042OtherBLUE CROSS BLUE SHIELD IL
ILK27469Medicare ID - Type UnspecifiedMEMBER NUMBER
IL03932042OtherBLUE CROSS BLUE SHIELD IL