Provider Demographics
NPI:1043619554
Name:SHADWICK, SUSAN LORENA (IMFT-S, LMFT, ATR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LORENA
Last Name:SHADWICK
Suffix:
Gender:F
Credentials:IMFT-S, LMFT, ATR
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LORENA
Other - Last Name:SNODGRASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IMFT-S, LMFT, ATR-BC
Mailing Address - Street 1:628 WOODLAKE CT
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3458
Mailing Address - Country:US
Mailing Address - Phone:213-631-3733
Mailing Address - Fax:
Practice Address - Street 1:628 WOODLAKE CT
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-3458
Practice Address - Country:US
Practice Address - Phone:213-631-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF.1700016106H00000X
CALMFT99844106H00000X
221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0232084Medicaid