Provider Demographics
NPI:1720193832
Name:BOGUE, SUSAN LOUISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LOUISE
Last Name:BOGUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4121
Mailing Address - Country:US
Mailing Address - Phone:815-562-3801
Mailing Address - Fax:815-562-4481
Practice Address - Street 1:920 W PRAIRIE DR STE F
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3123
Practice Address - Country:US
Practice Address - Phone:815-899-0501
Practice Address - Fax:815-899-2098
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490024791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical