Provider Demographics
NPI:1003128448
Name:GILMOR, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GILMOR
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 1:12882 MANCHESTER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1858
Mailing Address - Country:US
Mailing Address - Phone:314-863-9912
Mailing Address - Fax:314-863-9918
Practice Address - Street 1:12882 MANCHESTER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1858
Practice Address - Country:US
Practice Address - Phone:314-863-9912
Practice Address - Fax:314-863-9918
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020381104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker