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General NPI Number Information
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NPI Number | 1952159550
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Entity Type | Individual
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Provider Name | MALISSA ROBY LSW
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Gender | Female
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Dates
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Enumeration Date | 05/08/2024
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Last Update Date | 05/08/2024
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Provider Practice Location Address
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Address Line | 755 ALMAR PKWY STE A
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City | BOURBONNAIS
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State | IL
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Zip | 60914-2393
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Country | US
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Telephone | 630-428-7890
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Fax |
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Provider Business Mailing Address
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Address Line | 787 DOUBLE JACK ST APT 2
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City | BOURBONNAIS
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State | IL
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Zip | 60914-9229
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Country | US
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Telephone | 312-890-4541
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150.106833
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License Number State | IL
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