Provider Demographics
NPI:1982319851
Name:ROETHLISBERGER, MEL (LSW)
Entity Type:Individual
Prefix:
First Name:MEL
Middle Name:
Last Name:ROETHLISBERGER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 FOXPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3290
Mailing Address - Country:US
Mailing Address - Phone:815-748-8334
Mailing Address - Fax:
Practice Address - Street 1:760 FOXPOINTE DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3290
Practice Address - Country:US
Practice Address - Phone:815-748-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
150.112518104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid