Provider Demographics
NPI:1073547204
Name:MARY ELLEN BRATU PSYD PC
Entity Type:Organization
Organization Name:MARY ELLEN BRATU PSYD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRATU
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-416-8440
Mailing Address - Street 1:32W081 ANDERSON LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9696
Mailing Address - Country:US
Mailing Address - Phone:630-416-8440
Mailing Address - Fax:
Practice Address - Street 1:1555 N NAPERVILLE WHEATON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1557
Practice Address - Country:US
Practice Address - Phone:630-416-8440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005052103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL612610Medicare ID - Type Unspecified