Healthcare Provider Details

I. General information

NPI: 1447355060
Provider Name (Legal Business Name): MELINDA R. STOLLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1747 W ROOSEVELT RD 456 WRB, MC 275
CHICAGO IL
60608-1264
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-996-0523
  • Fax: 312-413-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number071005858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: