Provider Demographics
NPI:1336507342
Name:BRUSA, NICCOLE K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICCOLE
Middle Name:K
Last Name:BRUSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 FAIRFIELD WAY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1588
Mailing Address - Country:US
Mailing Address - Phone:630-309-2989
Mailing Address - Fax:
Practice Address - Street 1:121 FAIRFIELD WAY
Practice Address - Street 2:SUITE 240
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1588
Practice Address - Country:US
Practice Address - Phone:630-309-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical