Healthcare Provider Details

I. General information

NPI: 1366379661
Provider Name (Legal Business Name): SUSAN ELIZABETH PRICE SSP, MAED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W A ST
BELLEVILLE IL
62220-1326
US

IV. Provider business mailing address

719 WHEATFIELD RD
O FALLON IL
62269-6106
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-4294
  • Fax:
Mailing address:
  • Phone: 618-830-9646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number250979
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: