Healthcare Provider Details

I. General information

NPI: 1396262069
Provider Name (Legal Business Name): SUSAN ELAINE PETERS SSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 BROADWAY
HAMILTON IL
62341
US

IV. Provider business mailing address

130 S. LAFAYETTE. SUITE 201
MACOMB IL
61455
US

V. Phone/Fax

Practice location:
  • Phone: 866-332-3880
  • Fax: 217-551-8002
Mailing address:
  • Phone: 309-837-3911
  • Fax: 309-833-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number152024
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: