Provider Demographics
NPI:1336497882
Name:STAUFFER, MELODY BETH
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:BETH
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:CHADWICK
Mailing Address - State:IL
Mailing Address - Zip Code:61014-0284
Mailing Address - Country:US
Mailing Address - Phone:815-622-8052
Mailing Address - Fax:
Practice Address - Street 1:1122 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARROLL
Practice Address - State:IL
Practice Address - Zip Code:61053-1461
Practice Address - Country:US
Practice Address - Phone:815-244-1376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011679101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional