Provider Demographics
NPI:1699856708
Name:THORNTON, MELISSA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:THORNTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:740 FAIRVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3016
Mailing Address - Country:US
Mailing Address - Phone:847-302-3069
Mailing Address - Fax:
Practice Address - Street 1:1121 E MAIN ST
Practice Address - Street 2:SUITE 130
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2205
Practice Address - Country:US
Practice Address - Phone:847-302-3069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633804Medicare UPIN
IL6268263Medicare UPIN