Provider Demographics
NPI:1891921144
Name:ETTER, SUSAN MARY
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:ETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:MARY
Other - Last Name:ETTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1610 CAMBRIA LN
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6079
Mailing Address - Country:US
Mailing Address - Phone:847-844-8258
Mailing Address - Fax:
Practice Address - Street 1:1610 CAMBRIA LN
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6079
Practice Address - Country:US
Practice Address - Phone:847-844-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.005753101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional