Healthcare Provider Details

I. General information

NPI: 1801824073
Provider Name (Legal Business Name): SUZANNE KISHEL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUZANNE WAHLS LCPC

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MONROE ST SUITE 307B
BLOOMINGTON IL
61701-3997
US

IV. Provider business mailing address

8 BRIARWOOD DR
DANVERS IL
61732-9197
US

V. Phone/Fax

Practice location:
  • Phone: 309-531-4721
  • Fax:
Mailing address:
  • Phone: 309-504-0259
  • Fax: 309-504-0259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180-005332
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180-005332
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-005332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: