Provider Demographics
NPI:1275990863
Name:SMITH, SUSAN STAPLES (LMHC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:STAPLES
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:ELIZABETH SUSAN
Other - Middle Name:STAPLES
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:1220 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2810
Mailing Address - Country:US
Mailing Address - Phone:800-539-4228
Mailing Address - Fax:
Practice Address - Street 1:702 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5332
Practice Address - Country:US
Practice Address - Phone:386-767-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13597101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health