Healthcare Provider Details

I. General information

NPI: 1528841012
Provider Name (Legal Business Name): MARISSA ANN BROWN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA ANN KROLL

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W PIONEER PKWY STE 14
PEORIA IL
61615-1882
US

IV. Provider business mailing address

2000 W PIONEER PKWY STE 14
PEORIA IL
61615-1882
US

V. Phone/Fax

Practice location:
  • Phone: 309-550-1001
  • Fax: 309-322-6470
Mailing address:
  • Phone: 309-550-1011
  • Fax: 309-322-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.015496
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: