Healthcare Provider Details

I. General information

NPI: 1932577376
Provider Name (Legal Business Name): MELISSA S KOSTIAL-JANOS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N GREENLEAF ST STE 228
GURNEE IL
60031-3393
US

IV. Provider business mailing address

1191 BLUE HERON CIR
ANTIOCH IL
60002-6403
US

V. Phone/Fax

Practice location:
  • Phone: 224-603-1199
  • Fax:
Mailing address:
  • Phone: 708-308-3938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number149001506
License Number StateIL

VIII. Authorized Official

Name: MELISSA SUSAN KOSTIAL-JANOS
Title or Position: PRESIDENT/ OWNER
Credential: LCSW ACSW
Phone: 224-603-1199