Provider Demographics
NPI:1679017297
Name:SUSAN L OSBORNE, LCSW
Entity Type:Organization
Organization Name:SUSAN L OSBORNE, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-371-1411
Mailing Address - Street 1:4631 NW 53RD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-3402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4631 NW 53RD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-3402
Practice Address - Country:US
Practice Address - Phone:352-371-1411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW75691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty