Provider Demographics
NPI:1699050609
Name:GLICK, SUSAN (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:GLICK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1257
Mailing Address - Country:US
Mailing Address - Phone:847-256-1999
Mailing Address - Fax:
Practice Address - Street 1:154 KENILWORTH AVE
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1257
Practice Address - Country:US
Practice Address - Phone:847-256-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146001952235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist