Provider Demographics
NPI:1821689852
Name:MOORE, MELISSA DELAROSA (EDD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:DELAROSA
Last Name:MOORE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:TERESA
Other - Last Name:DELAROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 S BRAINARD AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2100
Mailing Address - Country:US
Mailing Address - Phone:708-579-6520
Mailing Address - Fax:
Practice Address - Street 1:100 S BRAINARD AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2100
Practice Address - Country:US
Practice Address - Phone:708-579-6520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2016676103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool