Healthcare Provider Details

I. General information

NPI: 1033735550
Provider Name (Legal Business Name): SPRINGSOURCE PSYCHOLOGICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD STE 520
CHICAGO IL
60604-3433
US

IV. Provider business mailing address

1770 HARRISON ST
GLENVIEW IL
60025-5065
US

V. Phone/Fax

Practice location:
  • Phone: 224-202-6260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUSAN FOTI MCCLANAHAN
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 312-337-6064