Provider Demographics
NPI:1063473296
Name:PEREZ, SUSAN WOODFORD (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:WOODFORD
Last Name:PEREZ
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 711
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:VA
Mailing Address - Zip Code:23181-0711
Mailing Address - Country:US
Mailing Address - Phone:804-921-2100
Mailing Address - Fax:
Practice Address - Street 1:26317 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-2727
Practice Address - Country:US
Practice Address - Phone:804-921-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040034641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008930651Medicaid