Healthcare Provider Details

I. General information

NPI: 1407597776
Provider Name (Legal Business Name): MS. MELANIE MCCUMMISKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 EXECUTIVE DR STE 337
AURORA IL
60504-8152
US

IV. Provider business mailing address

1123 N PRAIRIE VIEW DR
KANKAKEE IL
60901-7398
US

V. Phone/Fax

Practice location:
  • Phone: 314-442-6183
  • Fax:
Mailing address:
  • Phone: 815-278-0575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178017942
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: