Provider Demographics
NPI:1639149701
Name:RICHARDSON, SUSAN MARY
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARY
Last Name:RICHARDSON
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 1:65 E MONROE ST UNIT 4314
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5737
Mailing Address - Country:US
Mailing Address - Phone:224-627-4908
Mailing Address - Fax:312-600-3880
Practice Address - Street 1:65 E MONROE ST UNIT 4314
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-5737
Practice Address - Country:US
Practice Address - Phone:224-627-4908
Practice Address - Fax:312-600-3880
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006027103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ39068Medicare UPIN
IL211298Medicare ID - Type Unspecified