Provider Demographics
NPI:1558427294
Name:VANBUREN, SUSAN E (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:E
Last Name:VANBUREN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103-2956
Mailing Address - Country:US
Mailing Address - Phone:770-877-9105
Mailing Address - Fax:770-877-9106
Practice Address - Street 1:127 SUMMER ST
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2956
Practice Address - Country:US
Practice Address - Phone:770-877-9105
Practice Address - Fax:770-877-9106
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
GACSW0046891041C0700X
NY07865811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241501OtherUNIVERA
NY000506354003OtherCOMMUNITY BLUE
NY00030241501OtherUNIVERA
GAN/AOtherBC/BS
GAN/AOtherBC/BS GA
NY000506354003OtherCOMMUNITY BLUE
GAN/AOtherMULTIPLAN