Provider Demographics
NPI:1285911149
Name:CLARK, SUSAN D (LCSW, MSW, ACSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW, MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N. WINFIELD RD.
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-4847
Mailing Address - Fax:630-933-4558
Practice Address - Street 1:25 N. WINFIELD RD.
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-4847
Practice Address - Fax:630-933-4558
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490047431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE (GROUP)
ILF400093421OtherMEDICARE (INDIVIDUAL0