Healthcare Provider Details

I. General information

NPI: 1043958176
Provider Name (Legal Business Name): SUSAN R WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 N CENTRAL AVE
CHICAGO IL
60639-1351
US

IV. Provider business mailing address

86 E 13TH ST
CHICAGO HEIGHTS IL
60411-2761
US

V. Phone/Fax

Practice location:
  • Phone: 773-360-1389
  • Fax:
Mailing address:
  • Phone: 708-466-9457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: