Provider Demographics
NPI:1639356793
Name:GALLOWAY, SUSAN KAYE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAYE
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:BORRESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1191 BROWNSMILL
Mailing Address - Street 2:
Mailing Address - City:ELSBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:63343
Mailing Address - Country:US
Mailing Address - Phone:636-697-2747
Mailing Address - Fax:573-898-2168
Practice Address - Street 1:104 MOUND
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379
Practice Address - Country:US
Practice Address - Phone:636-697-2747
Practice Address - Fax:573-898-2168
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007031028101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639356793Medicaid