Provider Demographics
NPI:1588077648
Name:HARRISON, SUSAN (RN, MSED)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:RN, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-1530
Mailing Address - Country:US
Mailing Address - Phone:309-762-5433
Mailing Address - Fax:309-762-4481
Practice Address - Street 1:2316 5TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-1530
Practice Address - Country:US
Practice Address - Phone:309-762-5433
Practice Address - Fax:309-762-4481
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 171M00000X, 172V00000X, 174H00000X
IL041.315152163W00000X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator