Provider Demographics
NPI:1043958176
Name:WALLACE, SUSAN R
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2761
Mailing Address - Country:US
Mailing Address - Phone:708-466-9457
Mailing Address - Fax:
Practice Address - Street 1:2715 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1351
Practice Address - Country:US
Practice Address - Phone:773-360-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health