Healthcare Provider Details

I. General information

NPI: 1255765855
Provider Name (Legal Business Name): SUSAN BEATRICE MOSHER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S MARION ST
OAK PARK IL
60302-2809
US

IV. Provider business mailing address

5934 W MIDWAY PARK
CHICAGO IL
60644-1845
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-7500
  • Fax: 708-383-7780
Mailing address:
  • Phone: 773-287-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006271
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: