MEDICARE: MELISSA A BOSHANS M.ED.

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
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1467700948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA A BOSHANS M.ED.

Provider Business Mailing Address
First Line	:	2627 N RIDGEWAY AVE
Second Line	:	3N
City	:	CHICAGO
State	:	IL
Zip	:	60647-1119
Country	:	US
Telephone Number	:	773-876-4090
Fax Number	:

Provider Business Practice Location Address
First Line	:	2627 N RIDGEWAY AVE
Second Line	:	3N
City	:	CHICAGO
State	:	IL
Zip	:	60647-1119
Country	:	US
Telephone Number	:	773-876-4090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2012
Last Update Date	:	08/15/2012

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