Provider Demographics
NPI:1548356843
Name:WILLET-KRUCHKO, SHELLIE LYNN (PHD)
Entity type:Individual
Prefix:
First Name:SHELLIE
Middle Name:LYNN
Last Name:WILLET-KRUCHKO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHELLIE
Other - Middle Name:LYNN
Other - Last Name:WILLET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:24W788 75TH ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-1684
Mailing Address - Country:US
Mailing Address - Phone:630-778-1055
Mailing Address - Fax:
Practice Address - Street 1:24W788 75TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565
Practice Address - Country:US
Practice Address - Phone:630-778-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005578103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical