Provider Demographics
NPI:1407195753
Name:SELF-PORTWINE, SUSAN MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:SELF-PORTWINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARY
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1430 OLIVE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2377
Mailing Address - Country:US
Mailing Address - Phone:314-206-3700
Mailing Address - Fax:
Practice Address - Street 1:7080 RIVERMONT TRL
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-2081
Practice Address - Country:US
Practice Address - Phone:314-643-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0050141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical