Provider Demographics
NPI:1659345007
Name:BRUELL, MARY C (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:BRUELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:BRUELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-671-8503
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF PSYCHIATRY
Practice Address - Street 2:221 NE GLEN OAK 7 WEST
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-671-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490089271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215036OtherBCBS
IL639810Medicare ID - Type UnspecifiedMEDICARE