Provider Demographics
NPI:1629736046
Name:MELGOZA, JOHANNA IVETTE (CRC, LPC)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:IVETTE
Last Name:MELGOZA
Suffix:
Gender:F
Credentials:CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 N OAKLEY AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4812
Mailing Address - Country:US
Mailing Address - Phone:773-877-4829
Mailing Address - Fax:
Practice Address - Street 1:17 N WABASH AVE STE 515
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4818
Practice Address - Country:US
Practice Address - Phone:313-312-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty