Provider Demographics
NPI:1033317151
Name:AUGUSTINE, SUSAN KAY (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073
Mailing Address - Country:US
Mailing Address - Phone:307-742-6222
Mailing Address - Fax:307-742-9905
Practice Address - Street 1:1277 N 15TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:307-742-6222
Practice Address - Fax:307-742-9905
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-583101YP2500X
WY583101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional