Provider Demographics
NPI:1770828287
Name:MORE, SUSANNAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNAH
Middle Name:
Last Name:MORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4209
Mailing Address - Country:US
Mailing Address - Phone:630-524-5845
Mailing Address - Fax:630-208-3007
Practice Address - Street 1:302 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4209
Practice Address - Country:US
Practice Address - Phone:630-524-5845
Practice Address - Fax:630-208-3007
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007768103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400100849OtherMEDICARE (INDIVIDUAL PTAN)
IL071007768Medicaid
IL206147OtherMEDICARE (GROUP PTAN)