MEDICARE: DR. MICHELLE SARAH KRUCEK PSY.D.

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	103TC0700X	Clinical Psychologist	071008135	IL

General Provider Information

NPI Number	:	1316230766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE SARAH KRUCEK PSY.D.

Provider Business Mailing Address
First Line	:	1 GOLFVIEW RD STE 4
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-1210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 GOLFVIEW RD STE 4
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-1210
Country	:	US
Telephone Number	:	847-726-2400
Fax Number	:

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

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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