Healthcare Provider Details

I. General information

NPI: 1427558121
Provider Name (Legal Business Name): SUZANNE WYCHOCKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 N HALSTED ST
CHICAGO IL
60614-5501
US

IV. Provider business mailing address

457 W DEMING PL
CHICAGO IL
60614-1718
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-4042
  • Fax:
Mailing address:
  • Phone: 415-310-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149024046
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.102974
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: