Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | IL | |
Y | 103TC0700X | Clinical Psychologist | IL |
NPI | 1003961855 |
---|---|
Provider Name | Susan Mackey |
First Address | Lincolnwood, IL 60712-3730 |
Second Address | Skokie, IL 60077-1389 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1632922 | BLUE CROSS PROVIDER NUMBE (01) | IL |