Provider Demographics
NPI:1083842405
Name:BLEVINS, SUSAN JEAN (MA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JEAN
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 DEWAR DRIVE
Mailing Address - Street 2:#2
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4973
Mailing Address - Country:US
Mailing Address - Phone:307-922-1420
Mailing Address - Fax:
Practice Address - Street 1:3214 DEWAR DRIVE
Practice Address - Street 2:#2
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4973
Practice Address - Country:US
Practice Address - Phone:307-922-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator