Provider Demographics
NPI:1104688589
Name:NELSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:NELSON
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 1:1100 JORIE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2219
Mailing Address - Country:US
Mailing Address - Phone:630-974-6602
Mailing Address - Fax:630-487-2411
Practice Address - Street 1:2448 S 102ND ST STE 180
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2150
Practice Address - Country:US
Practice Address - Phone:630-974-6602
Practice Address - Fax:630-487-2411
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111421231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical