Provider Demographics
NPI:1073873535
Name:MCLELLAN, SUSANA MONTENEGRO (LCPC, NCC, CADC)
Entity Type:Individual
Prefix:MS
First Name:SUSANA
Middle Name:MONTENEGRO
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:LCPC, NCC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6516 N GREENVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5008
Mailing Address - Country:US
Mailing Address - Phone:773-899-3245
Mailing Address - Fax:
Practice Address - Street 1:4753 N BROADWAY ST
Practice Address - Street 2:SUITE 720
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5266
Practice Address - Country:US
Practice Address - Phone:773-899-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC231141101Y00000X
IL28375101YA0400X
IL180008189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)