Provider Demographics
NPI:1275119075
Name:LUSTBADER, MELANIE (LPC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:LUSTBADER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1147
Mailing Address - Country:US
Mailing Address - Phone:312-243-8487
Mailing Address - Fax:
Practice Address - Street 1:300 W ADAMS STREET
Practice Address - Street 2:SUITE 514
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-5108
Practice Address - Country:US
Practice Address - Phone:312-578-9990
Practice Address - Fax:312-275-7663
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015915101YP2500X
178.015915101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional