Healthcare Provider Details

I. General information

NPI: 1205721784
Provider Name (Legal Business Name): SUSAN NINOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W BARTLETT RD STE 14C
BARTLETT IL
60103-4454
US

IV. Provider business mailing address

850 W BARTLETT RD STE 14C
BARTLETT IL
60103-4454
US

V. Phone/Fax

Practice location:
  • Phone: 630-864-7267
  • Fax:
Mailing address:
  • Phone: 630-864-7267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.022219
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: