Healthcare Provider Details

I. General information

NPI: 1073374336
Provider Name (Legal Business Name): MELISSA MOONEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5537 N CLARK ST # B1
CHICAGO IL
60640-0751
US

IV. Provider business mailing address

5537 N CLARK ST # B1
CHICAGO IL
60640-0751
US

V. Phone/Fax

Practice location:
  • Phone: 773-454-1807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.019703
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.019703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: