Provider Demographics
NPI:1760617062
Name:BROUSIL, MELISSA R (BA, MAOL)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:R
Last Name:BROUSIL
Suffix:
Gender:F
Credentials:BA, MAOL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17390 OTTAWA AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3235
Mailing Address - Country:US
Mailing Address - Phone:708-212-0300
Mailing Address - Fax:
Practice Address - Street 1:2445 BIRDSALL ST
Practice Address - Street 2:APT# 5
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1748
Practice Address - Country:US
Practice Address - Phone:708-212-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-16
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst