Provider Demographics
NPI:1700969060
Name:LAFFERTY, MARY SUE P (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY SUE
Middle Name:P
Last Name:LAFFERTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:P
Other - Last Name:LAFFERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2530 CRAWFORD AVE
Mailing Address - Street 2:#304
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4970
Mailing Address - Country:US
Mailing Address - Phone:847-475-8625
Mailing Address - Fax:847-869-8116
Practice Address - Street 1:2530 CRAWFORD AVE
Practice Address - Street 2:#304
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4970
Practice Address - Country:US
Practice Address - Phone:847-475-8625
Practice Address - Fax:847-869-8116
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001673728OtherBLUE CROSS
IL245190Medicaid