Provider Demographics
NPI:1942704093
Name:GREGORY, MELISSA (LPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GRADY DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1503
Mailing Address - Country:US
Mailing Address - Phone:630-659-5973
Mailing Address - Fax:
Practice Address - Street 1:15127 S 73RD AVE STE C
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3463
Practice Address - Country:US
Practice Address - Phone:708-586-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012252101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional