Provider Demographics
NPI:1396023396
Name:BROWNBACK, MELISSA R (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:BROWNBACK
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 WHITE OAK ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3724
Mailing Address - Country:US
Mailing Address - Phone:847-461-3406
Mailing Address - Fax:
Practice Address - Street 1:1625 WHITE OAK ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3724
Practice Address - Country:US
Practice Address - Phone:847-461-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007010101YP2500X
CA4726101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional