Provider Demographics
NPI:1639231608
Name:DOMINE, SUSAN ARLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ARLEEN
Last Name:DOMINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER CMR 402
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:637-186-8590
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035071041C0700X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical