Healthcare Provider Details

I. General information

NPI: 1407976731
Provider Name (Legal Business Name): MELISSA SCHRUCK CCC, SLP-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3420
  • Fax: 309-664-3422
Mailing address:
  • Phone: 217-326-2911
  • Fax: 217-344-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1460008541
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: