Provider Demographics
NPI:1972666709
Name:RICHTER, SUSANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:RICHTER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 ELM PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2538
Mailing Address - Country:US
Mailing Address - Phone:847-234-4015
Mailing Address - Fax:847-234-4015
Practice Address - Street 1:480 ELM PL
Practice Address - Street 2:SUITE 104
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2538
Practice Address - Country:US
Practice Address - Phone:847-234-4015
Practice Address - Fax:847-234-4015
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006792103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04925695OtherBLUE SHIELD PROVIDER NUMB