MEDICARE: MARISSA ANN BROWN LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180.015496	IL

General Provider Information

NPI Number	:	1528841012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA ANN BROWN LCPC

Provider Business Mailing Address
First Line	:	4211 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-691-5502
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-691-5502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	08/23/2023

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Directions to “ MARISSA ANN BROWN LCPC” Practice Location

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