Provider Demographics
NPI:1679024061
Name:SURRATT, CODIE
Entity Type:Individual
Prefix:
First Name:CODIE
Middle Name:
Last Name:SURRATT
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 1:520 WILSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4944
Mailing Address - Country:US
Mailing Address - Phone:512-964-3386
Mailing Address - Fax:
Practice Address - Street 1:620 WING ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:512-964-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor