Provider Demographics
NPI:1053314799
Name:MYERS, SUSAN GIBSON (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GIBSON
Last Name:MYERS
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:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-0246
Mailing Address - Country:US
Mailing Address - Phone:276-679-0162
Mailing Address - Fax:276-679-0164
Practice Address - Street 1:18 SEVENTH ST
Practice Address - Street 2:PARK AVE CENTER, SUITE 207
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273
Practice Address - Country:US
Practice Address - Phone:276-679-0162
Practice Address - Fax:276-679-0164
Is Sole Proprietor?:No
Enumeration Date:2005-05-25
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040015491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010143047Medicaid
VA175710OtherBCBS
VA175710OtherBCBS
VAR89333Medicare UPIN