Provider Demographics
NPI:1801238985
Name:CLARK, SUSAN LEIGHTON (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGHTON
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 N SHERIDAN RD
Mailing Address - Street 2:#1001
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1957
Mailing Address - Country:US
Mailing Address - Phone:773-597-7388
Mailing Address - Fax:
Practice Address - Street 1:5445 N SHERIDAN RD
Practice Address - Street 2:#1001
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1957
Practice Address - Country:US
Practice Address - Phone:773-597-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0152111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical