Provider Demographics
NPI:1114653946
Name:SUSANNE NEAL DBA CLEARWATER COUNSELING
Entity Type:Organization
Organization Name:SUSANNE NEAL DBA CLEARWATER COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER- LICENCES PROFESSIONAL OCUNSE
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:BRIDGETTE
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC LAC
Authorized Official - Phone:719-293-0750
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-0759
Mailing Address - Country:US
Mailing Address - Phone:719-293-0750
Mailing Address - Fax:
Practice Address - Street 1:1206 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3327
Practice Address - Country:US
Practice Address - Phone:719-293-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0014244Medicaid