Provider Demographics
NPI:1639589179
Name:SUE HOWELL-FAFCHAMPS LCSW LLC
Entity Type:Organization
Organization Name:SUE HOWELL-FAFCHAMPS LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWELL-FAFCHAMPS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:803-719-2190
Mailing Address - Street 1:3711 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 202 OFFICE 1
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0951
Mailing Address - Country:US
Mailing Address - Phone:803-719-2190
Mailing Address - Fax:706-432-9095
Practice Address - Street 1:3711 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 202 OFFICE 1
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0951
Practice Address - Country:US
Practice Address - Phone:803-719-2190
Practice Address - Fax:706-432-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0042381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I803969OtherMEDICARE PTAN 202I803969