Provider Demographics
NPI:1427125855
Name:GAULT, SUSAN J (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:GAULT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 LAKE COOK RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4920
Mailing Address - Country:US
Mailing Address - Phone:847-940-8996
Mailing Address - Fax:847-267-0002
Practice Address - Street 1:770 LAKE COOK RD
Practice Address - Street 2:SUITE 250
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4920
Practice Address - Country:US
Practice Address - Phone:847-940-8996
Practice Address - Fax:847-267-0002
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001673500OtherBCBS PROVIDER #