Provider Demographics
NPI:1417067190
Name:SUSARLA, VIJAYALAKSHMI (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:SUSARLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 CONESTOGA RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2491
Mailing Address - Country:US
Mailing Address - Phone:630-975-1610
Mailing Address - Fax:630-246-6809
Practice Address - Street 1:2628 83RD ST
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-1661
Practice Address - Country:US
Practice Address - Phone:630-246-6810
Practice Address - Fax:630-246-6809
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005075103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK05522Medicare ID - Type Unspecified