Provider Demographics
NPI:1528194651
Name:ANDERSON, SUSAN LYNNE (MSW, LISW, DCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSW, LISW, DCSW
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:LYNNE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LISW, DCSW
Mailing Address - Street 1:5965 RENAISSANCE PL
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4709
Mailing Address - Country:US
Mailing Address - Phone:419-882-5678
Mailing Address - Fax:419-882-7446
Practice Address - Street 1:5965 RENAISSANCE PL
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4709
Practice Address - Country:US
Practice Address - Phone:419-882-5678
Practice Address - Fax:419-882-7446
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00039481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHANSW23742Medicare ID - Type Unspecified