Healthcare Provider Details

I. General information

NPI: 1962056150
Provider Name (Legal Business Name): MELORA HARDWICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 GREENLEAF DR
JOLIET IL
60436-9724
US

IV. Provider business mailing address

2401 W MAIN ST
MARION IL
62959-1188
US

V. Phone/Fax

Practice location:
  • Phone: 708-277-7991
  • Fax:
Mailing address:
  • Phone: 618-997-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178010411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: