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General NPI Number Information
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NPI Number | 1013613892
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Entity Type | Individual
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Provider Name | SANDRA SUSAN CROSS LCSW
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Gender | Female
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Dates
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Enumeration Date | 02/03/2023
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 809 W DETWEILLER DR STE 810
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City | PEORIA
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State | IL
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Zip | 61615-2140
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Country | US
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Telephone | 309-264-9517
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Fax |
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Provider Business Mailing Address
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Address Line | 2522 W STRONEHENGE CT
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City | PEORIA
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State | IL
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Zip | 61615
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Country | US
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Telephone | 309-264-9517
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149019468
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 149019468
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License Number State | IL
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