Healthcare Provider Details

I. General information

NPI: 1568418739
Provider Name (Legal Business Name): SUSAN ROBERTA DAVIS LCPC, CDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 VALLEY VIEW RD
GURNEE IL
60031-1041
US

IV. Provider business mailing address

2845 VALLEY VIEW RD
GURNEE IL
60031-1041
US

V. Phone/Fax

Practice location:
  • Phone: 847-502-1007
  • Fax: 815-301-9025
Mailing address:
  • Phone: 847-502-1007
  • Fax: 815-301-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.007623
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS12630298P
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.007623
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: