Provider Demographics
NPI:1518142330
Name:WALL, MELANIE (MA, LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:MA, LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PYOTT RD STE 208A
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-9798
Mailing Address - Country:US
Mailing Address - Phone:224-326-4200
Mailing Address - Fax:
Practice Address - Street 1:880 EAST OAK STREET UNIT 1A
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156
Practice Address - Country:US
Practice Address - Phone:224-326-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional