Provider Demographics
NPI:1447481411
Name:ENGELHARDT, SUSAN EILEEN
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:EILEEN
Last Name:ENGELHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 WELLS STREET RD
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-4171
Mailing Address - Country:US
Mailing Address - Phone:618-542-5421
Mailing Address - Fax:618-542-5556
Practice Address - Street 1:1308 WELLS STREET RD
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-4171
Practice Address - Country:US
Practice Address - Phone:618-542-5421
Practice Address - Fax:618-542-5556
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178004845101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor