Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | IL | |
N | 103T00000X | Psychologist | IL | |
N | 103G00000X | Clinical Psychologist | IL | |
N | 103TC0700X | Clinical Psychologist | IL | |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | IL | |
N | 103TF0000X | Family Psychologist | IL |
NPI | 1033260047 |
---|---|
Provider Name | Dr. Susan R Smith |
First Address | Grayslake, IL 60030-3563 |
Second Address | Grayslake, IL 60030-7817 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2007 |
Last Update Date | 08/07/2007 |