Provider Demographics
NPI:1689189177
Name:GRACE, SUSAN ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:GRACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W JACKSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-536-6621
Mailing Address - Fax:618-453-1102
Practice Address - Street 1:305 W JACKSON ST STE 200
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0106991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-010699OtherSTATE LICENSE