Provider Demographics
NPI:1114040227
Name:VALESSARES, SUSAN CHRISTINE (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CHRISTINE
Last Name:VALESSARES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SQUIRE LN
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1413
Mailing Address - Country:US
Mailing Address - Phone:630-881-7601
Mailing Address - Fax:630-513-6839
Practice Address - Street 1:3 SQUIRE LN
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1413
Practice Address - Country:US
Practice Address - Phone:630-881-7601
Practice Address - Fax:630-513-6839
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006810103G00000X, 103TA0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent