Provider Demographics
NPI:1093853533
Name:BRENNAN, MELISSA (EDS, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:EDS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BAYVIEW RD
Mailing Address - Street 2:
Mailing Address - City:FOX RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60021-1501
Mailing Address - Country:US
Mailing Address - Phone:847-302-6488
Mailing Address - Fax:
Practice Address - Street 1:1248 AMERICAN WAY
Practice Address - Street 2:SUITE B
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3936
Practice Address - Country:US
Practice Address - Phone:847-302-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional