Provider Demographics
NPI:1194018994
Name:TERRELL, SUSAN R (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:TERRELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 N DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5813
Mailing Address - Country:US
Mailing Address - Phone:773-396-6750
Mailing Address - Fax:
Practice Address - Street 1:429 N MARION ST
Practice Address - Street 2:SUITE 205
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1800
Practice Address - Country:US
Practice Address - Phone:773-396-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490073161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical