Provider Demographics
NPI:1790375491
Name:WILLIAMS, MELISSA EVAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:EVAN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W WELLINGTON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7187
Mailing Address - Country:US
Mailing Address - Phone:312-757-6748
Mailing Address - Fax:
Practice Address - Street 1:1011 W WELLINGTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7187
Practice Address - Country:US
Practice Address - Phone:312-757-6748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1790375491OtherBLUE CROSS BLUE SHIELD OF ILLINOIS