Provider Demographics
NPI:1215228390
Name:MEDLIN, SUZANNE MACTAGGART (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MACTAGGART
Last Name:MEDLIN
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-381-8336
Mailing Address - Fax:704-381-8332
Practice Address - Street 1:3541 RANDOLPH RD
Practice Address - Street 2:SUITE 206
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1082
Practice Address - Country:US
Practice Address - Phone:704-381-8336
Practice Address - Fax:704-381-8332
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0065591041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009037Medicaid