Provider Demographics
NPI:1053448662
Name:MELON-GRACE PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:MELON-GRACE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MELON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:630-920-9113
Mailing Address - Street 1:911 N ELM ST
Mailing Address - Street 2:SUITE 316
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3634
Mailing Address - Country:US
Mailing Address - Phone:630-920-9113
Mailing Address - Fax:
Practice Address - Street 1:911 N ELM ST
Practice Address - Street 2:SUITE 316
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3634
Practice Address - Country:US
Practice Address - Phone:630-920-9113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060007829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001605025OtherBLUE CROSS
IL584660Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER