Provider Demographics
NPI:1255692794
Name:WAGNER-SCHUMAN, MELISSA LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LYNNE
Last Name:WAGNER-SCHUMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 S WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4300
Mailing Address - Country:US
Mailing Address - Phone:312-996-0123
Mailing Address - Fax:312-413-1228
Practice Address - Street 1:912 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4300
Practice Address - Country:US
Practice Address - Phone:312-996-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.144446208000000X, 2084P0804X, 2084P0800X
OH35.1294572084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry