Provider Demographics
NPI:1043344211
Name:FECZKO, SUSAN (STA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FECZKO
Suffix:
Gender:F
Credentials:STA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 S INDIANA AVE APT 319
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1577
Mailing Address - Country:US
Mailing Address - Phone:773-744-5508
Mailing Address - Fax:
Practice Address - Street 1:1010 N HOOKER ST STE 301
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4633
Practice Address - Country:US
Practice Address - Phone:312-943-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2170000742355S0801X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103034Medicaid
IL103034Medicaid