Provider Demographics
NPI:1134653132
Name:DOURMASHKIN, SUSANNAH C (LPCC)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:C
Last Name:DOURMASHKIN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 BECKNER ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-6351
Mailing Address - Country:US
Mailing Address - Phone:505-989-4500
Mailing Address - Fax:505-443-8360
Practice Address - Street 1:4730 BECKNER ROAD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-989-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0211141101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional