Provider Demographics
NPI:1700157575
Name:GLICKMAN, MELISSA GINA
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:GINA
Last Name:GLICKMAN
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 1:8 OAK CREEK DR. #1809
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089
Mailing Address - Country:US
Mailing Address - Phone:224-717-6214
Mailing Address - Fax:
Practice Address - Street 1:1383 ABBOTT DR APT 1
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1865
Practice Address - Country:US
Practice Address - Phone:847-931-9798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health