MEDICARE: EZZA MELINA AHMAD MUSTAFFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	178.014078	IL
2	101YP2500X	Professional Counselor	180.015151	IL

General Provider Information

NPI Number	:	1669029542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EZZA MELINA AHMAD MUSTAFFA

Provider Business Mailing Address
First Line	:	878 N PAULINA ST APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5093
Country	:	US
Telephone Number	:	515-817-3828
Fax Number	:

Provider Business Practice Location Address
First Line	:	2045 W NORTH AVE STE 2B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5413
Country	:	US
Telephone Number	:	773-249-2921
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2019
Last Update Date	:	02/13/2024

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