Provider Demographics
NPI:1457323529
Name:O DELL, SUSAN LINDA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LINDA
Last Name:O DELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:O DELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1422 W THOME AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1820
Mailing Address - Country:US
Mailing Address - Phone:773-262-7010
Mailing Address - Fax:773-381-7889
Practice Address - Street 1:1422 W THOME AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1820
Practice Address - Country:US
Practice Address - Phone:773-262-7010
Practice Address - Fax:773-381-7889
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149 0007351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1673585OtherBLUE CROSS BLUE SHIELD
IL1673585OtherBLUE CROSS BLUE SHIELD