Provider Demographics
NPI:1811125412
Name:SUBERLAK, KATHERINE M
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:SUBERLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:M
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2606
Mailing Address - Country:US
Mailing Address - Phone:708-383-0113
Mailing Address - Fax:708-386-1391
Practice Address - Street 1:14 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2606
Practice Address - Country:US
Practice Address - Phone:708-383-0113
Practice Address - Fax:708-386-1391
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0136501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical