Provider Demographics
NPI:1639542442
Name:SUSAN MILLHAM LICSW PLLC
Entity Type:Organization
Organization Name:SUSAN MILLHAM LICSW PLLC
Other - Org Name:MILLHAM PSYCHOTHERAPY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:304-435-3494
Mailing Address - Street 1:7000 COOMBS FARM RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-0803
Mailing Address - Country:US
Mailing Address - Phone:304-435-3494
Mailing Address - Fax:
Practice Address - Street 1:7000 COOMBS FARM RD STE 202
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-0803
Practice Address - Country:US
Practice Address - Phone:304-435-3494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSAN MILLHAM LICSW PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-03
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
WVDP00944194261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty