Provider Demographics
NPI:1972147163
Name:MELTON, JOSH LIAM
Entity type:Individual
Prefix:
First Name:JOSH
Middle Name:LIAM
Last Name:MELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 W NORTH SHORE AVE # 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5603
Mailing Address - Country:US
Mailing Address - Phone:414-758-4849
Mailing Address - Fax:
Practice Address - Street 1:1223 W NORTH SHORE AVE # 2W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-5603
Practice Address - Country:US
Practice Address - Phone:414-758-4849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician