Provider Demographics
NPI:1598509499
Name:MELISSA ILLARIO, LICENSED CLINICAL SOCIAL WORKER PC
Entity type:Organization
Organization Name:MELISSA ILLARIO, LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:TACY
Authorized Official - Last Name:ILLARIO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-615-3160
Mailing Address - Street 1:1044 N ANAHEIM BLVD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-7567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1044 N ANAHEIM BLVD UNIT 2
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-7567
Practice Address - Country:US
Practice Address - Phone:801-615-3160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty