Provider Demographics
NPI:1548348659
Name:KEOGH, SUSAN M (LCPC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:KEOGH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 KAYS DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-532-3390
Mailing Address - Fax:
Practice Address - Street 1:405 KAYS DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-862-0064
Practice Address - Fax:309-862-1542
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180001161101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
101694OtherHEALTH ALLIANCE
5723204OtherBCBS
202808OtherMHN