Provider Demographics
NPI:1396262069
Name:PETERS, SUSAN ELAINE (SSP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELAINE
Last Name:PETERS
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S. LAFAYETTE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455
Mailing Address - Country:US
Mailing Address - Phone:309-837-3911
Mailing Address - Fax:309-833-2367
Practice Address - Street 1:1830 BROADWAY
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:IL
Practice Address - Zip Code:62341
Practice Address - Country:US
Practice Address - Phone:866-332-3880
Practice Address - Fax:217-551-8002
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152024103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool