Provider Demographics
NPI:1366081366
Name:PRUSKO, MELISSA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIE
Last Name:PRUSKO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 BUCKSKIN LN
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-9104
Mailing Address - Country:US
Mailing Address - Phone:630-267-7235
Mailing Address - Fax:
Practice Address - Street 1:618 LIBRARY PL
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2908
Practice Address - Country:US
Practice Address - Phone:847-733-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
IL071.010411103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist