Provider Demographics
NPI:1306024765
Name:SMITH, SUSAN S (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:S
Last Name:SMITH
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 1:300 BRANNON BEND
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330
Mailing Address - Country:US
Mailing Address - Phone:334-393-0388
Mailing Address - Fax:
Practice Address - Street 1:301 ANDREWS AVENUE
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0012451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical