Healthcare Provider Details

I. General information

NPI: 1134406739
Provider Name (Legal Business Name): MELISSA ANN PRUSHA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 WHITE DEER DR
ALGONQUIN IL
60102-6315
US

IV. Provider business mailing address

3660 WHITE DEER DR
ALGONQUIN IL
60102-6315
US

V. Phone/Fax

Practice location:
  • Phone: 847-863-1844
  • Fax: 847-458-2663
Mailing address:
  • Phone: 847-863-1844
  • Fax: 847-458-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149009792
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: