Provider Demographics
NPI:1083987127
Name:ELDRIDGE, LYNN SUZANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:SUZANNE
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:SUZANNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1418 MACCORKLE AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1331
Mailing Address - Country:US
Mailing Address - Phone:304-348-1419
Mailing Address - Fax:304-348-1017
Practice Address - Street 1:1418 MACCORKLE AVE SW STE A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1331
Practice Address - Country:US
Practice Address - Phone:304-348-1419
Practice Address - Fax:304-348-1017
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009404611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical