Provider Demographics
NPI:1053493189
Name:NIMROD, SUSAN DIANE (LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:NIMROD
Suffix:
Gender:F
Credentials:LCPC
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 860513
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66286
Mailing Address - Country:US
Mailing Address - Phone:913-530-0158
Mailing Address - Fax:
Practice Address - Street 1:3515 S 4TH STREET
Practice Address - Street 2:PROFESSIONAL ASSOCIATION
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-651-8415
Practice Address - Fax:913-772-8580
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS213101Y00000X
MO2000152681101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS33078027OtherBCBS KANSAS