1073002556 NPI number — MRS. SUSAN BERNICE BRODERICK LCSW

Table of content: MRS. SUSAN BERNICE BRODERICK LCSW (NPI 1073002556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073002556 NPI number — MRS. SUSAN BERNICE BRODERICK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODERICK
Provider First Name:
SUSAN
Provider Middle Name:
BERNICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073002556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11925 ELLWOOD GREENS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENOA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60135-8142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-751-6884
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40W222 LAFOX RD STE P2B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CHARLES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60175-7625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-751-6884
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149012332 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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