Provider Demographics
NPI:1689601296
Name:STICHA, SUSAN MARIE (ATR-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:STICHA
Suffix:
Gender:F
Credentials:ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-2213
Mailing Address - Country:US
Mailing Address - Phone:618-210-1203
Mailing Address - Fax:
Practice Address - Street 1:820 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-2213
Practice Address - Country:US
Practice Address - Phone:618-210-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional