Provider Demographics
NPI:1780370627
Name:ERICKSON, SUSAN (LSW, PEL)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LSW, PEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5142
Mailing Address - Country:US
Mailing Address - Phone:847-502-5646
Mailing Address - Fax:
Practice Address - Street 1:101 W VALLETTE ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4419
Practice Address - Country:US
Practice Address - Phone:844-984-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108650104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker