Provider Demographics
NPI:1083253124
Name:JAMES, SUSAN DIANE (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:JAMES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MATTS WAY
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63341-2525
Mailing Address - Country:US
Mailing Address - Phone:314-413-3200
Mailing Address - Fax:636-987-2080
Practice Address - Street 1:5336 MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63304-8002
Practice Address - Country:US
Practice Address - Phone:314-413-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017043247101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional