Provider Demographics
NPI:1801668009
Name:PETERSON, MELISSA ANN (MSW, LSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16627 DORCHESTER PL
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-6010
Mailing Address - Country:US
Mailing Address - Phone:708-421-0975
Mailing Address - Fax:
Practice Address - Street 1:16614 W 159TH ST STE 302
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8009
Practice Address - Country:US
Practice Address - Phone:708-341-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3195341041S0200X
IL150.109431104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool