Healthcare Provider Details

I. General information

NPI: 1427059476
Provider Name (Legal Business Name): MELISSA I. HARRIS LCPC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1000
US

IV. Provider business mailing address

11901 SWEARINGEN DR APT 80
AUSTIN TX
78758-2254
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4444
  • Fax: 618-939-4181
Mailing address:
  • Phone: 309-502-9597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39004182A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.006909
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178004427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: