Provider Demographics
NPI:1720352164
Name:ELLIOTT-BROGAN, MELISSA DAWN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DAWN
Last Name:ELLIOTT-BROGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 822
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-0822
Mailing Address - Country:US
Mailing Address - Phone:631-509-2575
Mailing Address - Fax:631-256-9353
Practice Address - Street 1:93 MAIN ST
Practice Address - Street 2:SUITE 1J
Practice Address - City:WEST SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11796-1832
Practice Address - Country:US
Practice Address - Phone:631-509-2575
Practice Address - Fax:631-256-9353
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0821821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical