Provider Demographics
NPI:1447221528
Name:STASEK, SUSAN (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STASEK
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 MIDLANE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9457
Mailing Address - Country:US
Mailing Address - Phone:847-293-0384
Mailing Address - Fax:
Practice Address - Street 1:2400 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6165
Practice Address - Country:US
Practice Address - Phone:847-377-8440
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71005965103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL71005965OtherLICENSE