Provider Demographics
NPI:1104540335
Name:RIVERA, SUSAN ALEXANDRA (LCPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ALEXANDRA
Last Name:RIVERA
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 1:1105 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4146
Mailing Address - Country:US
Mailing Address - Phone:312-744-1157
Mailing Address - Fax:
Practice Address - Street 1:1713 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2014
Practice Address - Country:US
Practice Address - Phone:312-742-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.016392101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty