Provider Demographics
NPI:1285629709
Name:MARVIN, SUSAN JEAN (LISW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JEAN
Last Name:MARVIN
Suffix:
Gender:F
Credentials:LISW
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 474
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-0474
Mailing Address - Country:US
Mailing Address - Phone:515-295-3334
Mailing Address - Fax:515-295-3337
Practice Address - Street 1:103 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:IA
Practice Address - Zip Code:50525-1430
Practice Address - Country:US
Practice Address - Phone:515-532-3338
Practice Address - Fax:515-532-3339
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA058651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA113858OtherHEALTH ALLIANCE
IA1700416535OtherGEHA
IA257155OtherCOMPSYCH
IA9385520OtherPRIVATE HEALTH CARE
IA244803OtherMIDLANDS CHOICE
IA39107OtherBLUE CROSS BLUE SHIELD
IA0482232Medicaid
IA11472254OtherCAQH
IA5682627OtherFIRST HEALTH
IA5682627OtherFIRST HEALTH
IA11472254OtherCAQH