Provider Demographics
NPI:1790290955
Name:STREET, SUSAN (SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3072
Mailing Address - Country:US
Mailing Address - Phone:874-341-4093
Mailing Address - Fax:
Practice Address - Street 1:524 E SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3510
Practice Address - Country:US
Practice Address - Phone:847-357-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.001124235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1353048KMedicaid