Provider Demographics
NPI:1326217860
Name:SUE LAFFERTY, PH.D., PC
Entity Type:Organization
Organization Name:SUE LAFFERTY, PH.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-475-8625
Mailing Address - Street 1:2530 CRAWFORD AVE
Mailing Address - Street 2:#304
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4970
Mailing Address - Country:US
Mailing Address - Phone:847-475-8625
Mailing Address - Fax:
Practice Address - Street 1:2530 CRAWFORD AVE
Practice Address - Street 2:#304
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4970
Practice Address - Country:US
Practice Address - Phone:847-475-8625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL245190Medicare PIN