Provider Demographics
NPI:1326392408
Name:BLOMBERG, SUZANNE GRANT (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:GRANT
Last Name:BLOMBERG
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 N LINCOLN AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2077
Mailing Address - Country:US
Mailing Address - Phone:773-255-7500
Mailing Address - Fax:
Practice Address - Street 1:4765 N LINCOLN AVE STE 209
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2077
Practice Address - Country:US
Practice Address - Phone:773-255-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008011101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health