Healthcare Provider Details

I. General information

NPI: 1578109740
Provider Name (Legal Business Name): MARQUITA CRUDUP LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1489 MERCHANT DR
ALGONQUIN IL
60102-5917
US

IV. Provider business mailing address

1489 MERCHANT DR
ALGONQUIN IL
60102-5917
US

V. Phone/Fax

Practice location:
  • Phone: 815-444-9700
  • Fax: 224-304-4664
Mailing address:
  • Phone: 815-444-9700
  • Fax: 224-304-4664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.014824
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: