Healthcare Provider Details

I. General information

NPI: 1659345007
Provider Name (Legal Business Name): MARY C BRUELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRIS BRUELL LCSW

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPT OF PSYCHIATRY 221 NE GLEN OAK 7 WEST
PEORIA IL
61636-0001
US

IV. Provider business mailing address

1 ILLINI DR
PEORIA IL
61605-2576
US

V. Phone/Fax

Practice location:
  • Phone: 309-671-8222
  • Fax:
Mailing address:
  • Phone: 309-671-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: