Provider Demographics
NPI:1477212314
Name:GALLAGHER, SUSAN MARY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 S PASFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3938
Mailing Address - Country:US
Mailing Address - Phone:217-220-0521
Mailing Address - Fax:
Practice Address - Street 1:2200 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-3454
Practice Address - Country:US
Practice Address - Phone:217-698-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health