Provider Demographics
NPI:1316632698
Name:MELVIN, ALYSSA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:MELVIN
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 1:1811 WILDSPRING PKWY
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8861
Mailing Address - Country:US
Mailing Address - Phone:630-373-1597
Mailing Address - Fax:
Practice Address - Street 1:112 KANSAS ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1447
Practice Address - Country:US
Practice Address - Phone:708-552-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013126101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional