Provider Demographics
NPI:1558361527
Name:BAISDEN, SUSAN CAROL (MS; PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:BAISDEN
Suffix:
Gender:F
Credentials:MS; PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CAROL
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3201
Mailing Address - Country:US
Mailing Address - Phone:304-235-3390
Mailing Address - Fax:304-235-3391
Practice Address - Street 1:41 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3201
Practice Address - Country:US
Practice Address - Phone:304-235-3390
Practice Address - Fax:304-235-3391
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV538101YM0800X
WV403103TC0700X
WVCP004526691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0163475000Medicaid
WVPR9340511Medicare ID - Type UnspecifiedGROUP #