Provider Demographics
NPI:1154963429
Name:LEE, SUSAN MARIE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CANNON RD
Mailing Address - Street 2:
Mailing Address - City:VOLO
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8180
Mailing Address - Country:US
Mailing Address - Phone:847-207-1006
Mailing Address - Fax:
Practice Address - Street 1:26177 W GRASS LAKE RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-9613
Practice Address - Country:US
Practice Address - Phone:847-395-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL42989103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool