Provider Demographics
NPI:1093492456
Name:STRUCK, MELISSA ANN (AUD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:STRUCK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:WIEDEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:330 MADISON ST STE 200
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6569
Practice Address - Country:US
Practice Address - Phone:815-314-5197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.001944231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist