Provider Demographics
NPI:1619634615
Name:BOB, SUE LYNNETTE
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:LYNNETTE
Last Name:BOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7622
Mailing Address - Country:US
Mailing Address - Phone:630-945-2977
Mailing Address - Fax:
Practice Address - Street 1:400 BILLINGS ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7622
Practice Address - Country:US
Practice Address - Phone:630-945-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health