Provider Demographics
NPI:1154604825
Name:O'CONNOR, MELISSA QUEEN (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:QUEEN
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:QUEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4319 N KENMORE AVE APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-0117
Mailing Address - Country:US
Mailing Address - Phone:908-797-8476
Mailing Address - Fax:
Practice Address - Street 1:2755 N PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6109
Practice Address - Country:US
Practice Address - Phone:872-215-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0166251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical