Provider Demographics
NPI:1184823973
Name:CHAMBLISS, SUSAN LARAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LARAINE
Last Name:CHAMBLISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:LARIANE
Other - Last Name:CAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:214 ASCOT PARADE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7847
Mailing Address - Country:US
Mailing Address - Phone:575-825-1183
Mailing Address - Fax:
Practice Address - Street 1:2360 INDIAN WELLS RD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4609
Practice Address - Country:US
Practice Address - Phone:575-437-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09921101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91978831Medicaid