Provider Demographics
NPI:1134131550
Name:COE, SUSAN JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JANE
Last Name:COE
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 1:800 MCHENRY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7487
Mailing Address - Country:US
Mailing Address - Phone:815-455-0590
Mailing Address - Fax:815-455-0592
Practice Address - Street 1:800 MCHENRY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7487
Practice Address - Country:US
Practice Address - Phone:815-455-0590
Practice Address - Fax:815-455-0592
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490035391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18356Medicare UPIN