Provider Demographics
NPI:1164775458
Name:GAMBACH, SUSAN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:GAMBACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:S.
Other - Middle Name:MARIE
Other - Last Name:GAMBACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:116 N CHESTNUT ST
Mailing Address - Street 2:SUITE 243
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4039
Mailing Address - Country:US
Mailing Address - Phone:217-637-1537
Mailing Address - Fax:
Practice Address - Street 1:1514 COUNTRY LAKE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-6428
Practice Address - Country:US
Practice Address - Phone:217-637-1537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490155161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149015516OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION LICENSE NUMBER