Provider Demographics
NPI:1255849386
Name:FOSTER, MELISSA (MED EDS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MED EDS
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BUCHHOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:919 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-4500
Mailing Address - Country:US
Mailing Address - Phone:815-547-7113
Mailing Address - Fax:
Practice Address - Street 1:919 E 6TH ST
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-4500
Practice Address - Country:US
Practice Address - Phone:815-547-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL994389103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty