Provider Demographics
NPI:1114936663
Name:SWISHER, SUSANNE M (PHD)
Entity Type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:M
Last Name:SWISHER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1167
Mailing Address - Country:US
Mailing Address - Phone:847-251-5489
Mailing Address - Fax:847-251-6666
Practice Address - Street 1:3545 LAKE AVE
Practice Address - Street 2:SUITE #200
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1058
Practice Address - Country:US
Practice Address - Phone:847-251-7350
Practice Address - Fax:847-853-2600
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004871103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL596760Medicare ID - Type Unspecified