Provider Demographics
NPI:1891918157
Name:MELTON, KRISTIN LESLIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LESLIE
Last Name:MELTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 COUNTY ROAD 300 N
Mailing Address - Street 2:
Mailing Address - City:NORRIS CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62869-3831
Mailing Address - Country:US
Mailing Address - Phone:618-378-2160
Mailing Address - Fax:
Practice Address - Street 1:1340 COUNTY ROAD 950 E
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-5024
Practice Address - Country:US
Practice Address - Phone:618-382-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional