Provider Demographics
NPI:1386984250
Name:DR. SUSAN SAMUEL, INC.
Entity type:Organization
Organization Name:DR. SUSAN SAMUEL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-240-6197
Mailing Address - Street 1:1812 BELLER RD
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N MCCLURG CT
Practice Address - Street 2:SUITE 3304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4323
Practice Address - Country:US
Practice Address - Phone:646-397-2685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
071.008447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty