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NPI Code Detail

MEDICARE: MELISSA QUEEN O'CONNOR LCSW

MEDICARE: MELISSA QUEEN O'CONNOR LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker149.016625IL

General Provider Information

NPI Number : 1154604825
Entity Type Code : Individual
Provider Name (Legal Business Name) : MELISSA QUEEN O'CONNOR LCSW
Provider Business Mailing Address
First Line : 4319 N KENMORE AVE APT 1S
Second Line :
City : CHICAGO
State : IL
Zip : 60613-0117
Country : US
Telephone Number : 908-797-8476
Fax Number :
Provider Business Practice Location Address
First Line : 2755 N PINE GROVE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60614-6109
Country : US
Telephone Number : 872-215-6676
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/20/2011
Last Update Date : 05/18/2021

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