Provider Demographics
NPI:1144237488
Name:JOHNSON, SUSANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:
Last Name:JOHNSON
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 1:728 OGDEN AVE
Mailing Address - Street 2:STE E
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2901
Mailing Address - Country:US
Mailing Address - Phone:630-640-2980
Mailing Address - Fax:
Practice Address - Street 1:728 OGDEN AVE
Practice Address - Street 2:STE E
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2901
Practice Address - Country:US
Practice Address - Phone:630-640-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006253103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IP558185OtherMAGELLAN BEHAVIORAL HEALT
IL2227588OtherBLUECROSSBLUESHIELD
IL2227588OtherBLUECROSSBLUESHIELD