Provider Demographics
NPI:1760410211
Name:MELTON, STACY STOKES (LCSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:STOKES
Last Name:MELTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:STOKES-MELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:612 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2662
Mailing Address - Country:US
Mailing Address - Phone:217-224-9484
Mailing Address - Fax:217-224-7894
Practice Address - Street 1:612 N 11TH ST
Practice Address - Street 2:STE B
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2662
Practice Address - Country:US
Practice Address - Phone:217-224-9484
Practice Address - Fax:217-224-7894
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149006584104100000X
MO20060346441041C0700X
IL149-0065841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL256514009Medicare PIN
ILF400267288Medicare PIN