Provider Demographics
NPI:1316076235
Name:SUSNJAR, MIRELLA (MD)
Entity type:Individual
Prefix:
First Name:MIRELLA
Middle Name:
Last Name:SUSNJAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5N315 DEERPATH WAY
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-4908
Mailing Address - Country:US
Mailing Address - Phone:630-587-5397
Mailing Address - Fax:
Practice Address - Street 1:750 S STATE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7612
Practice Address - Country:US
Practice Address - Phone:630-587-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry