Provider Demographics
NPI:1104936749
Name:ALLEN, SUSAN D (MS LCPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:D
Other - Last Name:PENNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS LCPC
Mailing Address - Street 1:8051 OLD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-8735
Mailing Address - Country:US
Mailing Address - Phone:815-608-1205
Mailing Address - Fax:
Practice Address - Street 1:8051 OLD RIVER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-8735
Practice Address - Country:US
Practice Address - Phone:815-608-1205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10132177OtherBLUE CROSS BLUE SHIELD ID