Healthcare Provider Details

I. General information

NPI: 1700969060
Provider Name (Legal Business Name): MARY SUE P LAFFERTY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUE P LAFFERTY PH.D.

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 CRAWFORD AVE #304
EVANSTON IL
60201-4970
US

IV. Provider business mailing address

2530 CRAWFORD AVE #304
EVANSTON IL
60201-4970
US

V. Phone/Fax

Practice location:
  • Phone: 847-475-8625
  • Fax: 847-869-8116
Mailing address:
  • Phone: 847-475-8625
  • Fax: 847-869-8116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071004575
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: