Provider Demographics
NPI:1568418739
Name:DAVIS, SUSAN ROBERTA (LCPC, NCSP, CDS)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ROBERTA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCPC, NCSP, CDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1041
Mailing Address - Country:US
Mailing Address - Phone:847-502-1007
Mailing Address - Fax:815-301-9025
Practice Address - Street 1:2845 VALLEY VIEW RD
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1041
Practice Address - Country:US
Practice Address - Phone:847-502-1007
Practice Address - Fax:815-301-9025
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007623101YP2500X
ILSS12630298P103TS0200X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILSS12630298POtherD.T., SCH PSYCH, EVALS
IL180.007623OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR