Healthcare Provider Details

I. General information

NPI: 1043344211
Provider Name (Legal Business Name): SUSAN FECZKO STA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N HOOKER ST STE 301
CHICAGO IL
60642-4633
US

IV. Provider business mailing address

1910 S INDIANA AVE APT 319
CHICAGO IL
60616-1577
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-3600
  • Fax:
Mailing address:
  • Phone: 773-744-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number217000074
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: