Provider Demographics
NPI:1174490841
Name:WILM, SUSANNE (BSW)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:WILM
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:MD
Other - Middle Name:
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:518 SW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8734
Mailing Address - Country:US
Mailing Address - Phone:772-873-8811
Mailing Address - Fax:772-873-8800
Practice Address - Street 1:518 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8734
Practice Address - Country:US
Practice Address - Phone:772-873-8811
Practice Address - Fax:772-873-8800
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-18
Last Update Date:2025-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M000000X101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty