Provider Demographics
NPI:1073150462
Name:SUSI, ALEXANDRA RAQUEL (LPC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:RAQUEL
Last Name:SUSI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5338 N PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2025
Mailing Address - Country:US
Mailing Address - Phone:561-504-7874
Mailing Address - Fax:
Practice Address - Street 1:5338 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2025
Practice Address - Country:US
Practice Address - Phone:561-504-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health