Provider Demographics
NPI:1699881656
Name:MCCRACKEN, SUSAN G (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1322
Mailing Address - Country:US
Mailing Address - Phone:815-735-9540
Mailing Address - Fax:773-926-0938
Practice Address - Street 1:1480 N NORTHWEST HWY
Practice Address - Street 2:SUITE 205
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1322
Practice Address - Country:US
Practice Address - Phone:815-735-9540
Practice Address - Fax:773-926-0938
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2013-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002723103T00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR17722Medicare UPIN