Provider Demographics
NPI:1326482878
Name:AMISON, MELISSA (MSED, MAEA, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:AMISON
Suffix:
Gender:F
Credentials:MSED, MAEA, LCSW
Other - Prefix:MS
Other - First Name:LYSSA
Other - Middle Name:
Other - Last Name:AMISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8829 BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-2104
Mailing Address - Country:US
Mailing Address - Phone:708-255-5053
Mailing Address - Fax:708-255-5120
Practice Address - Street 1:3504 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1302
Practice Address - Country:US
Practice Address - Phone:708-255-5053
Practice Address - Fax:708-255-5120
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011016651041C0700X
IL149.01587741041C0700X
MN297041041C0700X
IN34008063A1041C0700X
IA1068761041C0700X
TX1041831041C0700X
NJ44SC062956001041C0700X
IL19963501041S0200X
IL149.0158741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1326482878INDMedicaid