Provider Demographics
NPI:1043201791
Name:FORTNEY-HARLAN, SUSAN L (MSW LISW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:L
Last Name:FORTNEY-HARLAN
Suffix:
Gender:F
Credentials:MSW LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 RYAN DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-8919
Mailing Address - Country:US
Mailing Address - Phone:513-523-3468
Mailing Address - Fax:
Practice Address - Street 1:10 N LOCUST ST
Practice Address - Street 2:SUITE B3
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-1192
Practice Address - Country:US
Practice Address - Phone:513-523-1706
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00082571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7210086OtherAETNA
000000176694OtherANTHEM
OHFOSW23991Medicare ID - Type Unspecified