Provider Demographics
NPI:1912353384
Name:GALLOWAY, SUSAN (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 N DIVISION ST
Mailing Address - Street 2:SUITE 509
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1802 N DIVISION ST
Practice Address - Street 2:SUITE 509
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1182
Practice Address - Country:US
Practice Address - Phone:815-941-3882
Practice Address - Fax:815-941-3884
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009393101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2063Medicare UPIN