Provider Demographics
NPI:1093594921
Name:WIMBERLEY, SUSANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:WIMBERLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W CANFIELD AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7953
Mailing Address - Country:US
Mailing Address - Phone:208-758-7111
Mailing Address - Fax:
Practice Address - Street 1:560 W CANFIELD AVE STE 300
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7953
Practice Address - Country:US
Practice Address - Phone:208-758-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38827101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health