Provider Demographics
NPI:1225436546
Name:SHERBON, SUSAN LYNN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:SHERBON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 GATEWAY BLVD APT 455
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-8889
Mailing Address - Country:US
Mailing Address - Phone:815-218-4928
Mailing Address - Fax:
Practice Address - Street 1:1760 GATEWAY BLVD APT 455
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-8889
Practice Address - Country:US
Practice Address - Phone:815-218-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
IL1490156781041S0200X, 1041C0700X
IL1-14-10063251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No251S00000XAgenciesCommunity/Behavioral Health