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General NPI Number Information
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NPI Number | 1649298324
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Entity Type | Organization
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Legal Business Name | SELF IMPROVEMENT THROUGH AWARENESS PC
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Dates
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Enumeration Date | 07/18/2006
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Last Update Date | 12/11/2013
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Provider Practice Location Address
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Address Line | 2628 83RD ST
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City | DARIEN
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State | IL
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Zip | 60561-1661
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Country | US
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Telephone | 630-975-1610
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Fax | 630-246-6809
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Provider Business Mailing Address
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Address Line | 632 CONESTOGA RD
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City | NAPERVILLE
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State | IL
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Zip | 60563-2491
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Country | US
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Telephone | 630-975-1610
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Fax | 630-246-6809
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST/PRESIDENT
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Name | DR. VIJAYALAKSHMI SUSARLA
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Credential | PH.D
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Telephone | 630-975-1610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071005075
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License Number State | IL
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