Provider Demographics
NPI:1124206313
Name:BOEHM, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:BOEHM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 ORANGE ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-2328
Practice Address - Country:US
Practice Address - Phone:828-350-8343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-10
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003722Medicaid