Provider Demographics
NPI:1275032815
Name:NIELSEN, SUSAN KAYE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAYE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 GEMMETT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5021
Mailing Address - Country:US
Mailing Address - Phone:208-419-6387
Mailing Address - Fax:
Practice Address - Street 1:2420 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7549
Practice Address - Country:US
Practice Address - Phone:208-542-1026
Practice Address - Fax:208-528-2945
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-37165104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker