Provider Demographics
NPI:1023467420
Name:FIDALE, MARY SUSAN (LCPC, RNC)
Entity type:Individual
Prefix:MS
First Name:MARY SUSAN
Middle Name:
Last Name:FIDALE
Suffix:
Gender:F
Credentials:LCPC, RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681281
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60168-1281
Mailing Address - Country:US
Mailing Address - Phone:847-217-6190
Mailing Address - Fax:
Practice Address - Street 1:4160 RT 83 SUITE 206
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-9585
Practice Address - Country:US
Practice Address - Phone:847-217-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003182101YP2500X
IL041.211850163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse