Provider Demographics
NPI:1841417722
Name:MYKET, SUSAN
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:MYKET
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 1:1754 N WASHINGTON ST
Mailing Address - Street 2:SUITE 104A
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1334
Mailing Address - Country:US
Mailing Address - Phone:630-245-1440
Mailing Address - Fax:630-245-1444
Practice Address - Street 1:1754 N WASHINGTON ST
Practice Address - Street 2:SUITE 104A
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1334
Practice Address - Country:US
Practice Address - Phone:630-245-1440
Practice Address - Fax:630-245-1444
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical