Healthcare Provider Details

I. General information

NPI: 1124513239
Provider Name (Legal Business Name): SUSAN MARIE WORTMAN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2018
Last Update Date: 06/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 202
CHICAGO IL
60601-7940
US

IV. Provider business mailing address

2603 W CORTLAND ST # 2
CHICAGO IL
60647-4210
US

V. Phone/Fax

Practice location:
  • Phone: 312-278-3054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.010657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: