Provider Demographics
NPI:1801070644
Name:GUNNING, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GUNNING
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 1:724 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3740
Mailing Address - Country:US
Mailing Address - Phone:618-465-7724
Mailing Address - Fax:618-465-7724
Practice Address - Street 1:724 LINDEN ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3740
Practice Address - Country:US
Practice Address - Phone:618-465-7724
Practice Address - Fax:618-465-7724
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist