Provider Demographics
NPI:1619246030
Name:STEPHAN, SUZANNE ELIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:ELIA
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5309
Mailing Address - Country:US
Mailing Address - Phone:815-332-6019
Mailing Address - Fax:815-332-6090
Practice Address - Street 1:8616 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5309
Practice Address - Country:US
Practice Address - Phone:815-332-6019
Practice Address - Fax:815-332-6090
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490127471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149012747OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION