Healthcare Provider Details

I. General information

NPI: 1902072440
Provider Name (Legal Business Name): GRETCHEN DEROSEAR MELVIN M.S., CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 COLLEGE AVE SUITE B
QUINCY IL
62301-2664
US

IV. Provider business mailing address

1025 MAINE ST
QUINCY IL
62301-4038
US

V. Phone/Fax

Practice location:
  • Phone: 217-228-3377
  • Fax: 217-228-2657
Mailing address:
  • Phone: 217-222-6550
  • Fax: 217-277-2253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147.000725
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: