Healthcare Provider Details

I. General information

NPI: 1073813382
Provider Name (Legal Business Name): SUZANNA ZAVALETA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNA HERNANDEZ PHD

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3000
  • Fax: 872-588-3021
Mailing address:
  • Phone: 872-588-3000
  • Fax: 872-588-3021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180007610
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008649
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: