MEDICARE: SUSAN KOGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	180-001774	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180.001774	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1952325250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KOGAN

Provider Business Mailing Address
First Line	:	2525 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4108
Country	:	US
Telephone Number	:	773-765-0594
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	12/13/2007

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Directions to “ SUSAN KOGAN ” Practice Location

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