Provider Demographics
NPI:1326144510
Name:SCHMIDT, SUSAN E
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 BENNETT DRIVE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5176
Mailing Address - Country:US
Mailing Address - Phone:630-922-6791
Mailing Address - Fax:630-922-6792
Practice Address - Street 1:1010 WEST 95TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643
Practice Address - Country:US
Practice Address - Phone:630-922-6791
Practice Address - Fax:630-922-6792
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004822103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL341091Medicare ID - Type Unspecified
IL680009095Medicare ID - Type UnspecifiedRAILROAD