Provider Demographics
NPI:1336693308
Name:MOYNIHAN, MELISSA ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROSE
Last Name:MOYNIHAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W ROSCOE ST APT 109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3661
Mailing Address - Country:US
Mailing Address - Phone:248-930-3349
Mailing Address - Fax:
Practice Address - Street 1:137 N OAK PARK AVE # 400
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1344
Practice Address - Country:US
Practice Address - Phone:708-386-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010999901041C0700X
IL149.0221661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical