Provider Demographics
NPI:1730125246
Name:STILLER, SUSAN B (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:B
Last Name:STILLER
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 1:710 HUNTER DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1812
Mailing Address - Country:US
Mailing Address - Phone:719-595-0020
Mailing Address - Fax:719-542-1634
Practice Address - Street 1:710 HUNTER DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1812
Practice Address - Country:US
Practice Address - Phone:719-595-0020
Practice Address - Fax:719-542-1634
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9830181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO034147Medicaid
CO302191OtherMEDICARE PTAN #302191