MEDICARE: DR. MARILYN K STUCKEY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	071002991	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001672914	OTHER	IL	BLUE CROSS & BLUE SHIELD

General Provider Information

NPI Number	:	1023199320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARILYN K STUCKEY PH.D.

Provider Business Mailing Address
First Line	:	477 E BUTTERFIELD RD STE 107
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-5622
Country	:	US
Telephone Number	:	630-430-8319
Fax Number	:

Provider Business Practice Location Address
First Line	:	477 E BUTTERFIELD RD STE 107
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-5622
Country	:	US
Telephone Number	:	630-430-8319
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	04/11/2022

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