Provider Demographics
NPI:1093195794
Name:MOHAN, SUPRIYA
Entity Type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:
Last Name:MOHAN
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 1:900 N WESTMORELAND RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1681
Mailing Address - Country:US
Mailing Address - Phone:847-535-8060
Mailing Address - Fax:847-535-8070
Practice Address - Street 1:900 N WESTMORELAND RD STE 220
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1681
Practice Address - Country:US
Practice Address - Phone:847-535-8060
Practice Address - Fax:847-535-8070
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490220031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical