Provider Demographics
NPI:1023199320
Name:STUCKEY, MARILYN K (PHD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:K
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 E BUTTERFIELD RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5622
Mailing Address - Country:US
Mailing Address - Phone:630-430-8319
Mailing Address - Fax:
Practice Address - Street 1:477 E BUTTERFIELD RD STE 107
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5622
Practice Address - Country:US
Practice Address - Phone:630-430-8319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002991103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001672914OtherBLUE CROSS & BLUE SHIELD
351260Medicare ID - Type Unspecified