Provider Demographics
NPI:1306217575
Name:WIES, SUSAN KATHLEEN (LCSW-A)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:WIES
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:MS
Other - First Name:KAT
Other - Middle Name:
Other - Last Name:WIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW-A
Mailing Address - Street 1:2732 ANN ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5111
Mailing Address - Country:US
Mailing Address - Phone:336-229-5905
Mailing Address - Fax:
Practice Address - Street 1:2732 ANN ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5111
Practice Address - Country:US
Practice Address - Phone:336-229-5905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0101121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical