Healthcare Provider Details

I. General information

NPI: 1801966700
Provider Name (Legal Business Name): SUSAN SHARP CORNELIUS L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST SUITE 202
CHICAGO IL
60611-2507
US

IV. Provider business mailing address

1 EAST SUPERIOR SUITE 202
CHICAGO IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-2740
  • Fax:
Mailing address:
  • Phone: 773-769-2740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: