MEDICARE: MELISSA AMISON

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1942992425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELISSA AMISON

Provider Business Mailing Address
First Line	:	3504 GRAND BLVD
Second Line	:
City	:	BROOKFIELD
State	:	IL
Zip	:	60513-1302
Country	:	US
Telephone Number	:	708-255-5053
Fax Number	:	708-255-5053

Provider Business Practice Location Address
First Line	:	3504 GRAND BLVD
Second Line	:
City	:	BROOKFIELD
State	:	IL
Zip	:	60513-1302
Country	:	US
Telephone Number	:	708-255-5053
Fax Number	:	708-255-5120

Authorized Official
Title or Position	:	OWER
Name	:	MS. MELISSA AMISON
Credential	:	M.S. ED, MAEA, LCSW
Telephone Number	:	708-255-5053

Provider Enumeration Date	:	05/23/2023
Last Update Date	:	05/23/2023

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