Provider Demographics
NPI:1427798768
Name:BUSTAMANTE, MELISSA (MSE)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5235 S LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-3734
Mailing Address - Country:US
Mailing Address - Phone:773-297-0851
Mailing Address - Fax:
Practice Address - Street 1:155 N MICHIGAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7940
Practice Address - Country:US
Practice Address - Phone:312-722-6656
Practice Address - Fax:312-292-1189
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker