Provider Demographics
NPI:1710255906
Name:BROUSIL, RICHARD MACUR (PSYD, LPHA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MACUR
Last Name:BROUSIL
Suffix:
Gender:M
Credentials:PSYD, LPHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1732
Mailing Address - Country:US
Mailing Address - Phone:773-257-5315
Mailing Address - Fax:
Practice Address - Street 1:1501 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1732
Practice Address - Country:US
Practice Address - Phone:773-257-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004678103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist