Provider Demographics
NPI:1447817713
Name:PELLOK HARRIS, BROOKE ANN (LPC)
Entity type:Individual
Prefix:
First Name:BROOKE ANN
Middle Name:
Last Name:PELLOK HARRIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 S STATE ROUTE 157 STE 200D
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1724
Mailing Address - Country:US
Mailing Address - Phone:618-659-5411
Mailing Address - Fax:618-659-5411
Practice Address - Street 1:2220 S STATE ROUTE 157 STE 200D
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1724
Practice Address - Country:US
Practice Address - Phone:618-659-5411
Practice Address - Fax:618-659-5411
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014379101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional