Provider Demographics
NPI:1134116502
Name:HENNIGE, SUSAN HELEN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:HELEN
Last Name:HENNIGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 E. SELTICE WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-619-0190
Mailing Address - Fax:208-619-0190
Practice Address - Street 1:1602 E SELTICE WAY
Practice Address - Street 2:SUITE D
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7082
Practice Address - Country:US
Practice Address - Phone:208-619-0190
Practice Address - Fax:208-619-0195
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW - 11361041C0700X
WALW 000085471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8940571OtherL&I CRIME VICTIMS
WAS46698Medicare UPIN
WA0008858181Medicare NSC