Provider Demographics
NPI:1629848155
Name:PERKINS, SUSAN WORTHINGTON (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:WORTHINGTON
Last Name:PERKINS
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 1:44 N VIRGINIA ST STE B
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4106
Mailing Address - Country:US
Mailing Address - Phone:815-363-0864
Mailing Address - Fax:815-569-4720
Practice Address - Street 1:44 N VIRGINIA ST STE B
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4106
Practice Address - Country:US
Practice Address - Phone:815-363-0863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015312101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.015312Medicaid