MEDICARE: MALISSA ROBY LSW

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	104100000X	Social Worker	150.106833	IL

General Provider Information

NPI Number	:	1952159550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALISSA ROBY LSW

Provider Business Mailing Address
First Line	:	787 DOUBLE JACK ST APT 2
Second Line	:
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-9229
Country	:	US
Telephone Number	:	312-890-4541
Fax Number	:

Provider Business Practice Location Address
First Line	:	755 ALMAR PKWY STE A
Second Line	:
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-2393
Country	:	US
Telephone Number	:	630-428-7890
Fax Number	:

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

Provider Enumeration Date	:	05/08/2024
Last Update Date	:	05/08/2024

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Directions to “ MALISSA ROBY LSW” Practice Location

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