Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 071-006810 | IL |
Y | 103TC0700X | Clinical Psychologist | 071-006810 | IL |
N | 103TA0700X | Adult Development & Aging Psychologist | 071-006810 | IL |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 071-006810 | IL |
NPI | 1114040227 |
---|---|
Provider Name | Susan Christine Valessares |
First Address | St Charles, IL 60174-1413 |
Second Address | St Charles, IL 60174-1413 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2007 |
Last Update Date | 15/07/2008 |