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General NPI Number Information
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NPI Number | 1073873535
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Entity Type | Individual
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Provider Name | SUSANA MONTENEGRO MCLELLAN LCPC, NCC, CADC
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Gender | Female
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Dates
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Enumeration Date | 05/18/2012
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Last Update Date | 05/18/2012
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Provider Practice Location Address
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Address Line | 4753 N BROADWAY ST SUITE 720
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City | CHICAGO
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State | IL
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Zip | 60640-5266
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Country | US
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Telephone | 773-899-3245
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Fax |
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Provider Business Mailing Address
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Address Line | 6516 N GREENVIEW AVE
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City | CHICAGO
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State | IL
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Zip | 60626-5008
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Country | US
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Telephone | 773-899-3245
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 231141
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 28375
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180008189
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License Number State | IL
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