Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 071009629 | IL |
Y | 103TC0700X | Clinical Psychologist | 071009629 | IL |
N | 103G00000X | Clinical Psychologist | 3374-57 | WI |
N | 103TC0700X | Clinical Psychologist | 3374-57 | WI |
NPI | 1003268061 |
---|---|
Provider Name | Dr. Melissa Lancaster |
First Address | Winfield, IL 60190-1295 |
Second Address | Winfield, IL 60190-1295 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2016 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
206147 | MEDICARE GROUP PTAN (01) | IL |
F400432863 | MEDICARE INDIVIDUAL PTAN (01) | IL |