Provider Demographics
NPI:1164771390
Name:SULLIVAN, MELISSA ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 TIMBER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-1703
Mailing Address - Country:US
Mailing Address - Phone:708-790-7799
Mailing Address - Fax:
Practice Address - Street 1:305 TIMBER RIDGE CT
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-1703
Practice Address - Country:US
Practice Address - Phone:708-790-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490112561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical