Provider Demographics
NPI:1659855856
Name:RAICA, SUSAN VIRGINIA (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:VIRGINIA
Last Name:RAICA
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SOMERSET CT
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-1940
Mailing Address - Country:US
Mailing Address - Phone:847-458-1145
Mailing Address - Fax:
Practice Address - Street 1:420 WING STREET,SUITE3
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-6012
Practice Address - Country:US
Practice Address - Phone:847-450-0524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000889101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional