Provider Demographics
NPI:1881230365
Name:RICHARDSON, MELISSA (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 N ARTESIAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2932
Mailing Address - Country:US
Mailing Address - Phone:248-894-3464
Mailing Address - Fax:
Practice Address - Street 1:4753 N BROADWAY ST STE 826
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4992
Practice Address - Country:US
Practice Address - Phone:773-317-3949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional