Healthcare Provider Details

I. General information

NPI: 1114430857
Provider Name (Legal Business Name): SUSIE LIANA MOYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 W 18TH ST STE 216
CHICAGO IL
60608-2400
US

IV. Provider business mailing address

4045 W 58TH ST
CHICAGO IL
60629-4432
US

V. Phone/Fax

Practice location:
  • Phone: 708-581-8018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: