Healthcare Provider Details

I. General information

NPI: 1770828287
Provider Name (Legal Business Name): SUSANNAH MORE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 RANDALL RD
GENEVA IL
60134-4209
US

IV. Provider business mailing address

302 RANDALL RD
GENEVA IL
60134-4209
US

V. Phone/Fax

Practice location:
  • Phone: 630-524-5845
  • Fax: 630-208-3007
Mailing address:
  • Phone: 630-524-5845
  • Fax: 630-208-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.007768
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071.007768
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: