Provider Demographics
NPI:1174578751
Name:BRINKLOW, SUSAN S (LCSW, ACSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:BRINKLOW
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 N UNIVERSITY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1393
Mailing Address - Country:US
Mailing Address - Phone:217-872-1700
Mailing Address - Fax:217-872-1366
Practice Address - Street 1:3040 N UNIVERSITY AVE STE 2
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1393
Practice Address - Country:US
Practice Address - Phone:217-872-1700
Practice Address - Fax:217-872-1366
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0146381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM16220012Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL ID#