=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265680508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN M. MULLEN LCSW, CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2008
-----------------------------------------------------
Last Update Date | 08/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4753 N BROADWAY ST SUITE 608
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-5266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-638-4234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5423 N WAYNE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-638-4234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.012495
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------