Healthcare Provider Details

I. General information

NPI: 1568386951
Provider Name (Legal Business Name): MADELYN BELVILLE SSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 W WASHINGTON ST
MACOMB IL
61455-2118
US

IV. Provider business mailing address

2313 MAPLE AVE
MACOMB IL
61455-3275
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-4161
  • Fax:
Mailing address:
  • Phone: 217-491-7719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2697194
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: