Provider Demographics
NPI:1639823776
Name:CORNISH, MELONEE (CRADC)
Entity Type:Individual
Prefix:
First Name:MELONEE
Middle Name:
Last Name:CORNISH
Suffix:
Gender:F
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-2266
Mailing Address - Country:US
Mailing Address - Phone:618-258-7592
Mailing Address - Fax:618-258-7645
Practice Address - Street 1:304 WESLEY DR
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-2266
Practice Address - Country:US
Practice Address - Phone:618-258-7592
Practice Address - Fax:618-258-7645
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL23977101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)