Provider Demographics
NPI:1710008396
Name:PRINCE, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PRINCE
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 1:6946 AMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-6844
Mailing Address - Country:US
Mailing Address - Phone:901-210-7463
Mailing Address - Fax:901-347-1330
Practice Address - Street 1:5676 STAGE RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4578
Practice Address - Country:US
Practice Address - Phone:901-210-7463
Practice Address - Fax:901-347-1330
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3920072Medicaid
TN4177584OtherBCBS
TN3920072Medicare PIN
TN3920072Medicaid
TN3920072Medicare Oscar/Certification