=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417067190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIJAYALAKSHMI SUSARLA PH.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 12/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2628 83RD ST
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-1661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-246-6810
-----------------------------------------------------
Fax | 630-246-6809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 632 CONESTOGA RD
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-2491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-975-1610
-----------------------------------------------------
Fax | 630-246-6809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 071005075
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------